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A N N U A L REPORT
SUMMARY OF PROCEEDINGS OF THE EIGHTH SESSION OF
TH E ADVISORY COUNCIL HELD AT SINGAPORE,
FEBRUARY 8th and 9th, 1934.
P rin te d by
G . H . K ia t & C o., L td.
S in g a p o re .
T A BLE
P a ge.
Budget for 1935
EPIDEMIOLOGICAL IN TE LL IG EN C E: —
d is e a s e
. . . .
in c id e n c e :—
Plague in Ports
Plague in Countries
Cholera in Ports
Cholera in Countries
Smallpox in Ports
Smallpox in Countries
in f e c t e d
s h ip s :—
p il g r im a g e
M EASURES AGAINST T H E IN TRODUCTION OF DISEASE:----
RESEARCH PROGRAM M E:----
LIAISON W IT H H E A L T H ADM INISTRATIONS: —
A N N EX ES: —
I. Spread of Plague by Maritime Traffic
II. Spread of Cholera by Maritime Traffic
III. Estimates for the year 1934
IV. Estimates for the year 1935
V. Yearly Accounts for 1933
VI. Compilation ofWeekly Wireless Bulletin . .
VII. Quarantine Notifications issued by Eastern Health
Administrations during 1933
S UM M ARY OF PROCEEDINGS OF T H E 8 T H SESSION O F T H E ADVISORY
C O U N C IL
ON THE WORK OF THE EASTERN BUREAU
d v is o r y
o u n c il .
The Advisory Council met at the offices of the Bureau, Singapore, on
March 29th, and continued its deliberations until Saturday, the 1st April. A
short summary of the proceedings, together with the resolutions, was printed with
the report for 1932. The Council, on the last day of the session, appointed Dr
Hermant, Inspector-General of Medical and Health Services, Indo-China, as
Chairman for the ensuing year and Dr. W u Lien-teh, Director of the National
Quarantine Service of China, Vice-Chairman. The meeting of the Council was
attended by delegates from each country represented upon it, with the exception
of British India. The Council was pleased to have the assistance, in addition,
of delegates from Hong Kong, Philippine Islands and Straits Settlements.
In December, Lieut. Colonel Russell assumed office as Public Health
Commissioner with the Government of India in succession to Major-General
Graham. The latter was the first Chairman of the Advisory Council and retained
this position for the first four years of the Council’s existence. His absence from
future Council meetings will be much regretted by the other members and by the
officials of the Bureau, who have received unfailing support from him throughout
his connection with its work. It is understood that Colonel Russell will in future
represent British India on the Council.
In view of the fact that less than twelve months would have elapsed if
the meeting of the Council for 1934 were held at the ordinary time, early in
February, it has been decided not to convene a full meeting of the Council in
the early part of 1934. It is hoped, however, that the Chairman and ViceChairman will be able to consult with the Director in regard to the programme
for 1934 and that an opportunity may present itself during the meeting of the
Far Eastern Association of Tropical Medicine, later in the year, for Members of the
Council to hold at least an informal discussion regarding the working of the Bureau.
It will be remembered that, when the constitution of the Advisory Council was under
consideration, a suggestion was approved that at intervals a meeting of representa
tives of all health authorities in the Eastern zone should be held, in addition to
meetings of the Advisory Council. Although this question has been previously
raised at meetings of the Advisory Council it has so far not been carried into
effect. It is, however, under consideration as to whether it may be possible to
organise such a meeting during 1935. If this could be done, the opportunity
would present itself for a discussion on rural hygiene in the Far-East, in regard to
which a considerable amount of information has already been forwarded by various
countries to the Bureau.
ssem bly .
The report of the Health Organisation, which was submitted during the
Fourteenth Assembly at Geneva, contains a reference to the extension of the
National Quarantine Service of China, by reason of which the Eastern Bureau
was able to obtain more rapid information regarding the epidemiological situation
of the ports under Chinese control. It also referred to the decision of the
Advisory Council in favour of creating at Singapore, under the auspices of the
Health Organisation and in collaboration with the Government of Straits Settle
ments, an international course of malariology, the theoretical and laboratory work
of which would be carried out at the Medical College at Singapore.
The Second Committee of the Assembly, which reviewed the Report of the
Health Organisation, referred to the function of the Eastern Bureau in circulating
immediate information regarding the existence of the major infectious diseases
in Eastern countries, and to the fact that Health Administrations are enabled by
reason of this rapid and regular information to take such measures as are essential
for their own protection with a full knowledge of the dangers to be met. The
advantage of acting on known information enables these Administrations to apply
only such measures as are necessary, and this indirectly is of considerable benefit
to the shipping community. The Assembly, in adopting a resolution expressing
its appreciation of the value of the results obtained by the Health Organisation,
included a paragraph expressing its gratification "at the increasing importance
of the part played by the Eastern Bureau in the prevention of pestilential diseases.”
o m m it t e e .
The Health Committee, during its twentieth session, held at Geneva in
October, had before it the report of the Eastern Bureau for 1932, together with
the resolutions adopted by the Advisory Council and the budgetary estimates
for the financial year 1934. After consideration of these documents the Health
Committee adopted the following resolution:
"The Health Committee:
"Approves the resolutions adopted by the Advisory Council of the
Eastern Bureau during its seventh session, and the budgetary provisions
"Notes with pleasure that the Advisory Council approved in principle
the convening, as soon as circumstances permit, of a Conference on Rural
Hygiene in the Far East;
"Recognises that the creation of international malaria courses at
Singapore, with the support of local authorities, offers a useful mani
festation of international co-operation;
"Expresses its gratitude to those Governments which, since the creation
of the Eastern Bureau, have by their special financial support given proof
of their interest in it.”
The Budget for 1935 has been prepared after careful consideration of the
actual expenditure in each of the last few years during which, on account of
the economic depression, it has been necessary to limit activities to an absolute
minimum consistent with carrying out our obligations to Eastern countries. In
fixing the total estimated expenditure at approximately the average figure of the
expenditure in 1931, 1932 and 1933, no allowance is made for unexpected develop
ments, nor for any increase in activity. The one item in which any marked
reduction has been possible is that for cables, and although it is certain, owing
to the new rates, that increased expenditure will be incurred on this item, it is
anticipated that the amount provided will suffice. It will not be possible to
effect any further economies of a substantial nature without cutting out one or
other of the means by which the epidemiological intelligence is circulated.
p id e m io l o g ic a l
I n t e l l ig e n c e .
This service continues to be the main purpose of the Bureau’s existence.
Since 1925, when the Bureau first commenced to function, efforts have been
directed towards the improvement of this service, and these efforts have met with
such success that the only real shortcomings at the present time are a lack of
cabled information in regard to the situation in Vladivostok and incomplete
knowledge of the exact situation in certain inland provinces of China and in
British Indian States.
Correspondence has taken place with the authorities in French India with
regard to the possibilities of expediting weekly returns, which at present are received
somewhat late. Arrangements have been come to by which cabled information,
and also information sent by post, will be despatched at such time as will enable
the Bureau to receive it at the same time as it reaches the Minister for the Colonies
The authorities of Portuguese India have at our request agreed to inform
the Bureau by cable in regard to any outbreak of plague, cholera and smallpox.
This is a considerable advance over the procedure previously adopted of sending
such information by post.
Monthly returns of infectious diseases continue to be received regularly
by post from Moscow and include information in regard to Vladivostok. Corres
pondence has taken place with the Director of the Foreign Sanitary Bureau at
Moscow in the hope that a direct cabled service from Vladivostok might be
arranged, but the Director of that Bureau was not prepared to adopt this sugges
tion, pointing out that international obligations were fulfilled by notifying Paris
of the situation at Vladivostok. It has been suggested to the official in question
that the information that is required in regard to Vladivostok is of such value
to Eastern Health Administrations that its despatch by cable to the Bureau is
most desirable, and would be welcomed in return for the weekly cable to Vladivostok
regarding the situation of ports in regular communication with it which the Bureau
sends regularly. It does not seem likely, however, that any improvement can be
expected, on account of the centralisation of information in Moscow and its
Canton, the Health Department of which regularly cables each week, com
menced during the year to supplement this information by the despatch of a
weekly postal return. Information is also being regularly received from Swatow,
from which port there had been some difficulty in receiving regular information.
Returns from this port are also included in the one received from the Director
of National Quarantine Service, Shanghai.
A weekly statistical report containing information about the port of Mwanza
is being received from Dar-es-Salaam and is additional to the other information
which comes regularly to hand from that source.
The outstanding alteration in regard to wireless bulletins during the year
has been the change ever in method of transmission from Saigon from longwave
to shortwave. Following a notification in advance from the late Governor-General
of French Indo-China that this change was to come into effect, communications
were sent to all Health Administrations in the Eastern area enquiring whether
facilities existed for receiving shortwave messages. Later, during the months of
May and June, a trial was made by transmitting from Saigon a clear language
message each week on shortwave, in addition to the code message on longwave.
Difficulties of reception were at first experienced by Japan and New
Zealand, but subsequently both countries notified the Bureau that the messages on
shortwave were being satisfactorily received. It has not been possible, however,
to receive the shortwave messages in the Union of South Africa or in the countries
along the East African Coast. Fortunately, however, the Tananarive station in
Madagascar has continued to receive the bulletin, and to re-transmit it on longwave
as hitherto every Saturday, and, in consequence, the African countries receive it
In addition to transmitting the weekly bulletin in code, Saigon is also using
clear language for this purpose and in this way the desire of the many countries
who expressed a preference for clear language messages has been met.
The value of the transmissions from Malabar Station continues to be very
definite, for, during the period when New Zealand and Japan were not able to
receive the shortwave message from Saigon, they were both able to pick up the
Malabar message, which, through the courtesy of the authorities concerned, is
now being transmitted in code, both on longwave and shortwave, each Saturday,
immediately preceding the summary in clear which, as before, is transmitted daily
from this station.
During the year only one definite failure to pick up the Saigon message
occurred, and this was at the Jutogh wireless station in India where a severe storm
was prevailing at the time. The failure was, however, only in respect of the code
message and the same difficulty was not experienced in respect of the clear
Two countries, namely, Fiji and Sandakan, expressed a perference that for
local reasons the Saigon message should continue to be transmitted at 1.30 G M T
Friday, instead of midnight, GM T, Thursday. As this was not possible,
Sandakan has altered the time at which it re-transmits the message from Saturday,
1 G M T, to Sunday, 1 G M T.
A very disquieting feature during the year was the number of occasions
on which mistakes occurred in the messages transmitted from Saigon. This was
found to be due almost entirely to mistakes in the cable offices, either at Singapore
or at Saigon. Strong representations were made on this point, and the number
of errors in the latter half of the year has been negligible. Fortunately the
mistakes have not been very serious, but the possibilities in this direction are
infinite. The necessity for a check at the earliest possible moment on the actual
bulletin transmitted was obvious, and, through the courtesy of the Naval Wireless
Station at Kranji, Singapore, the Bureau now obtains, each Friday morning, by
telephone, the text of the actual message received. This enables immediate action
to be taken to remedy any mistake that may occur. In addition, a circular (see
Annex No. VI) was issued to all Health Administrations, advising them of the
basis on which the bulletin is prepared. This knowledge of the methods used
enables any Health Administration to determine at once from their situation
in the bulletin, when unusual returns are received, whether or not a mistake has
actually occurred, although naturally it is not possible to know what the correction
should be. It is hoped in this way that Administrations, where errors do occur,
will not be misled into applying quarantine measures unnecessarily. Through the
courtesy of the Director-General of Hêalth, Bangkok, and the Officer in Charge
of the Wireless Station at Penaga, additional checks on the message received
from Saigon and from Malabar are being obtained, and the thanks of the Bureau
are extended to those responsible.
No alteration has been possible in the number of ports to which weekly
cables are sent. W ith the change in method of wireless transmission, the authorities
in Persia were asked if it was now possible for them to pick up the message, but
replies have not been received. The ports to which cables are regularly sent are
Vladivostok, Canton, Bushire, Basrah, Aden and Victoria (Seychelles). During
the year advice was received regarding an alteration in both the method of using
cables and in the charges therefor. Ten-letter code words could no longer be
used after the end of 1933 and had to be replaced by five-letter messages. The
decision that these five-letter words need not be pronounceable enables the Bureau
to omit a number of the letters "A” which were previously required in the tenletter words, and to some extent this will reduce the costs of cabling. It is
certain, however, that this particular item will be,a source of increased expenditure
The pages of the "AA” Code giving the date of Saturdays from 1st
January 1934 to 31st December 1937 have been renewed, and a new set of pages
circulated to all code holders. Notification has also been sent to such persons
that the change in cable regulations makes it unnecessary to insert additional A’s
when using the code. The alteration in the cable regulations makes it more urgent
that the revision of the "AA” Code, which is at present in process, should be
Advances which have occurred in regard to the airmail services are to some
extent making it unnecessary to use the cable service as frequently as before, and
although, up to the present, this change is not of very great importance, it is
probable that in the future extended use can be made of airmail services, particularly
if the time of the journey between Singapore and Geneva can be further reduced.
It is hoped that the time will also come very soon when it is possible to telephone
from Geneva to Singapore, and although at first it is likely that this method of
communication will be costly and not entirely satisfactory, these minor difficulties
are bound to be overcome. It is obvious that when such a means of communica
tion is effected an increasing degree of co-ordination between the Bureau and the
Epidemiological Section of the Health Organisation can occur with advantage
to both offices.
W E EK L Y FASCICU LU S.
To meet the suggestion put forward by the Advisory Council that an
endeavour should be made to determine whether the Weekly Fasciculus could
include all the information received by individual Eastern Administrations from
various sources, an innovation has been made by including in certain issues
particulars of the situation in various countries in regard to minor infectious
diseases. This will be continued, and the views of Administrations will be invited
as to the value of the procedure after further trial. The situation in certain
countries in regard to particular diseases was also referred to in various issues of
the Fasciculus during the year, an example of which is the short summary contained
in the issue of the 13th October of the position in Japan during 1932 and 1933
in regard to dysentery. A summary of the epidemiological situation in the
Austral-Pacific Zone, in regard to which returns are received through the DirectorGeneral of Health for Australia, at Canberra, was made for the first half of the
year 1933, and appears in the issue of the 1st December. In addition, a summary
of the epidemiological situation in the Eastern arena for the third quarter of the
year was published in the issue of the 6th October.The idea underlying the
inclusion of summaries of this nature is to make the Fasciculus less a document
containing figures and dates only than it has previously been.
is e a s e
I n c id e n c e .
PL A G U E I N PO RTS.
Compared with the previous five years the incidence of plague in Eastern
ports has been relatively slight. This applies more particularly to ports in the
Near-East, such as Alexandria, Port Said, Suez and to Tamatave. It also applies
to Rangoon and, to a lesser extent, to Colombo.
Tamatave has shown a steady diminution in the number of cases reported
in each of the five years preceding the present one, the diminution being from
67 cases in 1928 to 2 cases in 1933.
BRITISH IN D IA .
Amongst the ports of British India Bombay and Bassein have recorded
the highest incidence of plague, while Rangoon figures are lower than any recorded
in the preceding five years.
Bombay has remained infected throughout the whole year, but the seasonal
incidence of cases has been maintained. O f the thirty-eight cases notified during
1933, thirty were recorded in the months of February, March and April. This
corresponds with the records of previous years which show that the heaviest incidence
has occurred between February and the early weeks of May. The figures for
1928 bring out this point very clearly in that, of 295 deaths recorded, 196 were
notified between the beginning of February and the middle of May.
Bassein has been the most heavily infected port of Burma, with a record
of fifty-three cases with forty-four deaths during the year. O f the deaths twenty
were notified in the period March 18th to May 6th and thirteen between July 8th
and August 12th. Human cases, however, have continued to occur sporadically
during other periods of the year.
Rangoon has reported eight cases with eight deaths among human beings,
which compares with thirty-six cases and twenty-seven deaths in the previous year.
The cases have occurred sporadically throughout the year, the greatest number
recorded during any one week being two.
O T H E R BRITISH POSSESSIONS.
Colombo:—Twenty-six cases and eighteen deaths have been reported from
Colombo. This compares very favourably with 1932, when sixty-seven cases with
sixty-one deaths were recorded, and with any of the preceding five years, in which
the lowest number of cases recorded, namely, thirty-seven cases and thirty deaths,
was 1929. In 1933, seventeen of the cases with eleven deaths were reported
in January and February. This was a continuation of the 1932 epidemic which
was responsible for twenty-one cases with nineteen deaths in the last quarter of
Singapore:—There had been no plague cases in Singapore from September
1929 until one case and one death were reported in the week ended 29th April,
1933. It occurred in the person of a caretaker of a godown where imported rice
had been stored. One definitely infected rat was found and several dead ones
too decomposed for examination.
The epizootic, however, was localised and
no further infected rodents or human cases were recorded during the year.
o u n t r ie s .
An isolated human case was reported from Bangkok, in the week ended
15th April, being the first case notified since January, 1932, when an isolated
case occurred. N o further cases were recorded during the year. In the five
years preceding 1933 there have been a number of cases each year in Bangkok,
and these have shown a tendency to occur in the early months of the year. It
was noted, for example, during the year 1931, that of sixteen cases recorded
fifteen occurred in January and February. The absence of cases in the latter half
of the year was, however, the most noticeable feature.
F R E N C H IN D O -C H IN A .
Saigon has recorded cases throughout the first three-quarters of the year
at irregular intervals, the total number being fifteen with ten deaths. O f the
previous five years, 1931 was the only year in which no cases were reported,
although the incidence in each of the other years of this period was very small.
Pnom-penh, on the other hand, has been somewhat more heavily infected,
thirty-seven cases and thirty-five deaths having been notified. The number of
cases has shown a considerable increase as compared with 1932, when seven only
were notified. The tendency has been for cases to crop up at any time during
the year in this port with an inclination towards greater prevalence in the first
three months of the year.
RODENT PLA G U E.
The degree to which attention was paid to examination of rodents for plague
infection varied in different ports. The returns showed that 4,000 or more rodents
were examined each week in Bombay, and it was rarely that all rodents were found
to be free from infection. The extent of the rodent infection varied definitely
with the season, a noticeable increase in the number found in Bombay being seen
during the latter half of February and throughout March and April. From the
end of April onwards the number found infected remained much smaller. Plagueinfected rodents have been detected in Bassein, where the greatest number was
found in April and May, but where odd infected rats were discovered throughout
other portions of the year. In Rangoon, however, where plague-infected rodents
have been found during the year, the most noticeable feature has been the absence
of infection amongst those examined from the middle of February until the end
of June, although the number examined remained steady during that period.
Colombo has found at intervals infection amongst the rodents, but here, as in
Rangoon, none was detected during the months of March, April, May and June.
The returns from ports show that plague infection is confined to a few
only, but that these are endemically infected, with seasonal exacerbations in certain
cases. The danger of transfer from these ports varies however. Bombay has a
large export trade in raw cotton which has been shown to be a suitable medium
for transfer of plague infection, while the main export from Rangoon and Bassein
consists of rice.
This again is incriminated as a medium suitable for plague
transfer. Ceylon, on the other hand, exports tea, rubber, coconuts, etc., products
which are not regarded as being in the category of rat-attracting cargo.
Bangkok being the centre for the export of rice from Siam, and Saigon for IndoChina, are both potentially dangerous, as is also Pnom-penh. There is, however,
a marked difference in the volume of merchandise exported from these ports. For
example, Bassein, though situated in the delta region of the Irrawaddy, and being
a collecting centre for rice, is only a minor port compared with Rangoon, through
which over 80% of the trade of Burma passes. Pnom-penh is accessible to ocean
going vessels, and, although of much less commercial importance than Saigon, it has
a large trade with the latter port and may be a source of plague infection of even
more importance. It is a noticeable fact that the principal port in British India
from which raw cotton is imported, as well as the principal ports of the chief riceexporting countries of the East, namely, Burma, Siam and Indo-China, are the
plague centres of the East.
PL AG U E I N
C O U N TR IE S -
The mortality curve for 1933 differs from that constructed from the mean
mortality figures for the preceding five-year period. The latter curve shows an
increase in prevalence through January and February, to reach an apex in March,
which is maintained until April, after which it falls quickly and the minimum
level occurs during June. This is followed by a gradual but definite rise through
out July, August, September and October, and from then on to the end of the
In 1933, however, the mortality remained at an almost constant level
throughout January, February and March, and at a much lower level than the
mean of the preceding five years. The tendency to fall throughout April and
May was present and the lowest level was reached in June. From this time
onwards, however, the mortality figures have risen more sharply than in the
previous five years and the mortality has
been much higher.
The provinces in which plague occurs are mainly three, Bombay, United
Provinces and Punjab. The alteration in the mortality curve is explained by a
comparison of the seasonal prevalence for the year in these, and, to a lesser extent,
in certain other provinces with that of the mean for the preceding five years.
The maximum seasonal prevalence in United Provinces occurs in March,
that of Punjab in April and of Bombay in October, while Central Provinces and
Bihar and Orissa also have their highest mortality in February and March. In
1933, however, the mortality in the United Provinces was much below the
average, reaching a maximum figure of 150 deaths only in the week
of heaviest mortality as compared with the mean maximum of 1,850 deaths in
one week for the preceding five years. The plague situation at this period of the
year in this province was thus the principal factor in determining the shape of
the curve for British India as a whole for the corresponding period.
In Punjab the difference in the maxima, though present, does not form
such a contrast. Central Provinces and Bihar and Orissa also had very much
diminished mortality figures for February and March as compared with the mean
quinquennial mortality, and this contributed to the shape of the curve.
The increased mortality in the latter half of the year however has been due
mainly to the situation in Bombay Presidency. A comparison of the curves for
British India and Bombay shows such a high degree of similarity as to suggest
that the situation in the Presidency was the main influence in determining the
situation in the country.
Bombay Presidency has returned a higher mortality for the year than
was recorded in any of the preceding five years. This increased mortality has been
most marked in September and October, which is the period of the seasonal
prevalence of plague. A comparison of the returns shows, however, that it is
in the southern registration district of the Presidency, which includes Belguam,
Bijapur, Dharwar, as well as in Poona town and district, that the increased
mortality has occurred, and not throughout the whole province. These are places
which have had a high mortality ever since plague was introduced.
Throughout 1933 the mortality in the southern registration district has been
continuous, with a definite decrease during May and June but with heavy mortality
figures in January, February and March, and again in August, September, October
and November. In Poona town and district the figures were low until July,
when a seasonal rise occurred, reaching epidemic proportions in September and
continuing throughout October and, to a lesser extent, in November. The
Plague Commission many years ago pointed out that in Poona town the weather
is hot and dry from March to the end of June and that during this period plague
is not epidemic.
Punjab:—As a contrast to the situation in Bombay, where plague is never
absent, the mortality for the Punjab is most striking. In this province plague is
epidemic but not endemic. During 1907 the mortality figure reached the huge
total of 600,000, while in 1933 less than 1,500 deaths were recorded, and of these
none occurred in either July or August.
The position is somewhat similar in United Provinces, although plague
there does not disappear completely in the hot months (July and August).
Madras is another example of a presidency in which the mortality has been
higher than that recorded in any of the previous five years. Russell, King and others
have pointed out the influence of geographical position on plague in Madras. This
is well shown by King and Pandit when discussing the average monthly plague
death rates per thousand for the period 1906-1925. The charts made from these
rates show that plague increases with the onset of the south-west monsoon in June
and July, and the curve then rises to an early peak in October in certain districts
such as Bellary, or it may rise to a later peak in January, the north-east monsoon
peak, in the more southern and eastern districts, such as Salem, Coimbatore and
Madura. For the presidency as a whole, the chart shows that the rise due to the
south-west monsoon is increased by the second or north-east monsoon, so that the
peak is reached in January. In the present year the mortality remained below
the average for the preceding five years in the early months of the year, but with
the onset of the south-west monsoon season commenced to rise above this figure to
a peak at the end of August, which, apart from one fall, was maintained through
out the whole of September. The mortality figures declined sharply in October,
though remaining still above the average for the preceding five-year period, but
rose again during November and December with the development of the north
As in Bombay Presidency, so also in Madras Presidency the mortality
figures show a marked variation in different districts. Four of these, namely,
Bellary, Madura, Salem and Coimbatore, are endemically infected, with a seasonal
epidemic prevalence, well marked in the case of the first three named. Bellary
district is wedged in between Nizam’s Dominions, Bombay Presidency and Mysore
State, and is thus exposed to repeated infections from each. Nizam’s Dominions
were invaded by plague in 1897, and by the end of 1898 every Southern district
in Bombay Presidency was infected, while Mysore was also invaded in the same
year. Russell states that indigenous plague in Bellary started in September 1898,
the infection having probably been introduced both from Bombay and from Nizam’s
Dominions. The district was the most heavily infected of any in Madras in 1933,
few weeks being reported free from deaths.
The lowest recorded mortality
occurred in April and May and the highest in the third week of August. King
and Iyer have shown the influence of hot weather in producing a marked diminution
in the number of fleas in Bellary and Coimbatore.
The lowest indices were
obtained in April and May, corresponding with the lowest mortality. The indices
show a tendency to rise with the appearance of monsoon conditions in August, the
highest being reached in November and December. The other three districts in
which the disease was endemic—Salem, Coimbatore and Madura—are situated
further south and are affected by the north-east monsoon. Salem and Coimbatore,
from their proximity to Mysore, are liable to repeated importations of the disease.
In the present year Salem district has been continuously infected, the mortality
gradually increasing from a minimum in April and May to a maximum in August
and September, but thereafter remaining at a lower level for the remainder of
The mortality curve in Coimbatore resembles that at Salem in having its
minimum in April and May, but the rise was less pronounced and a small but
more uniform number of deaths was reported for the remainder of the year.
King and Iyer, in their surveys of Bellary and Coimbatore, have found
that the percentage of rats without fleas varies with the season, and this was
particularly marked in the case of X. Cheopis. In the cold weather only 1.4%
of rats in Coimbatore and 3.4% in Bellary were without X. Cheopis, as compared
with 21.14% and 27.2% respectively in the hot season April and May. They
point out that this great rise in hot weather in the percentage of rats found without
any X. Cheopis is suggestive of how seasonal factors act in stopping plague.
Madura was infected in 1910 from Coimbatore district and reinfected in
1915. Since 1918 the disease has appeared almost yearly in the Kambam Valley,
where the insanitary conditions prevailing in villages favour a large rat population.
(Rat Flea Survey Madras Presidency—King and others). In this area the following
additional factors favour plague—a high Cheopis index, frequent and unrestricted
movement of grain and ideal climatic conditions. The mortality figures were
very low in April and May and the maximum mortality was in January and
Indian States-.—The returns from the Indian States are incomplete, but
the States of Hyderabad and Mysore and the Indian States in Bombay Presidency
have shown a considerable mortality, in the group of Indian States and agencies,
which includes the Indian States in Bombay Presidency, there was a heavy mortality
in January, February and March, followed by a minimum mortality in April and
May. This was followed by a marked rise to maximum figures at the end of
August. Again, towards the end of October, a very high mortality was recorded
which was due probably to the influence of the Bombay States, which have recorded
a higher mortality in 1933 than in any of the preceding five years.
In Hyderabad the heaviest recorded weekly mortality occurred at the end
of August, and again at the end of October. High figures were recorded also
during January, February and March, followed by minimum figures in April
Mysore returns for 1933 show that the early months of the year, January
and February, which with December form the cold season, had a high mortality,
but that the maximum figures were reached in October during the wet season.
The period of minimum mortality was during May, i.e. at the end of the hot
season. Iyer found in his survey that X. Brasiliensis formed 51% of the total
fleas captured, and, according to King and Iyer, the Mysore plateau is the chief
habitat of X. Brasiliensis. They suggest that this is perhaps due to this species
requiring a still lower temperature than X. Cheopis in which to multiply. The
survey of Mysore city showed that while the percentage of rats without X. Astia
was very noticeable, (44%-83%), very few rats caught were without Cheopis or
Brasiliensis. Plague appeared almost certainly to be carried by one or both of
the species Cheopis or Brasiliensis, but the possibility of Astia playing any part
in the transmission cf the disease in nature in Mysore seemed very small. In
Davangere, an important cotton centre of Mysore, the X. Cheopis index in the
cotton mills was very high. The comment is made that cotton appears to offer
exceptionally good conditions for the existence and multiplication of X. Cheopis.
All the rats captured in the cotton mills and godowns harboured fleas. It is suggested
that the varying indices of Brasiliensis met with in different districts indicates an
association between this species and the grain trade.
Sporadic cases of plague were reported during the first three months of
the year from four provinces in Ceylon, namely, Central, Western, Southern and
Uva provinces. One small outbreak at Dondra in Southern Province was of
pneumonic type; here twelve cases were recorded between the 5th to the 18th
March, of which eleven died.
Plague has been widely spread in Burma during 1933, although its incidence
has everywhere been relatively small and the total figures for the year show a
definite improvement over those for 1932. The mortality curve drawn from
the mean figures for the previous five years shows a much higher peak in the
first three months of the year than was reached in 1933. The lowest mortality
in 1933 as usual occurred during the months of May and June. Hirst has drawn
attention to the fact that the meteorological conditions in Rangoon are suitable
for the spread of plague throughout the year, but that there are two seasons when
the prevalence is greatest, namely, February,March and April, and July and
August. This he considers applicable to Lower Burma generally, while in Upper
Burma as a rule there is only a Spring rise, with the maximum in February. O f
the towns, Mandalay has been most heavily infected, with regular reports of human
cases throughout February, March and April, but with nope during May and
June. From July onwards, however, human cases have been regularly reported. In
Bassein town the minimum prevalence in May and June was noticeable, but, apart
from this, human cases have occurred at intervals throughout the rest of the year.
Rangoon town, on the other hand, has been generally free from human cases,
apart from a few sporadic ones.
Among the districts the most severely affected have been Magwe and
Meiktila, but in Myingyan, Thaton and Tharrawaddy there has been considerable
mortality also. In Magwe and Meiktila districts human cases were reported
throughout the whole of the first three months of the year, but April, May and
June were entirely free. In Meiktila district the mortality reached a maximum
in July, whereas in Magwe district the maximum mortality did not occur until
September. In Myingyan district, situated adjacent to these two, the heaviest
mortality has occurred in November and December although cases were present
in March, and again in August, September and October, with the usual minimum
in May and June. In Tharrawaddy district the prevalence in the first quarter
of the year, and again in July, August and September, was approximately the
same, but a free period was present in May and June. Thaton province, situated
in Lower Burma, has not shown the same seasonal prevalence. In this province
human cases commenced in April and continued until September, with only a
slight intermission in the early part of June. Akyab, as well as Mergui and
Tavoy districts has remained free from the disease. These districts, as Hirst has
pointed out, are "Astia” areas, but the extent to which this fact plays a part in the
continuance of their favourable plague situation remains to be determined.
The story of plague in Java from 1911 to 1923 has been presented in detail
by Dr. Otten, at that time head of the Plague Prevention Service. The first
phase cf the epidemic was the discovery of the presence of the disease in 1911 in
several residencies of East Java where it spread more or less rapidly. The port
of entry of the infection may have been Soerabaia, where cases were present in
1911, but this is not definitely proved. This phase reached its climax in 1914 and,
towards the end of that year, the mortality showed a rapid decrease.
The disease had thus far remained in the eastern part of the country, but
by 1915 an extension further west had taken place, the first authentic human
case being discovered in the early months of this year in Soerakarta. Towards
the end of 1915 the disease assumed epidemic proportions in the capital, but did
not spread to neighbouring areas.
In 1916 the port of Semarang was infected, and from 1917 onwards there
was a slow spread of infection into the hinterland until 1919, when the character of
the disease changed and it assumed an explosive form. During the next eight years
the disease spread over an extensive area of mid-Java, a large portion of which was
situated in mountainous country, the mortality being high in 1921, 1924 and 1925
to 1927, with the peak of the epidemic period in 1924. This may be taken as the
second phase of the epidemic.
In 1920 Batavia was found to be infected, as was Cheribon in 1922. From
both of these ports the mountains in West Java were threatened, but it was not
until 1929 that the third chapter of the disease commenced with the discovery of
human plague in Bandoeng, in the Preangan Residency of West Java. The
infection in this area probably spread from Cheribon Residency which had remained
infected. As in East and Mid-Java the spread of the disease in West Java was
slow at first, but towards the end of 1932, and in 1933, it assumed an explosive
form again, partly in Bandoeng Regency, but to a more marked extent in the
mountains of Garoet.
There is what Otten calls a periodic fluctuation, if not a definite seasonal
prevalence, of plague in Java. The increase starts in the third quarter of the
year, which is the period of greatest heat and dryness, and reaches its apex in the
fourth quarter. The decline takes place about the end of the year, which is in
the middle of the wet monsoon at a time when both the saturation deficiency and
temperature show a low monthly average. (Otten: Problem of the Seasonal
Prevalence of Plague). The minimum period is in the middle period of the
year, namely, the second quarter and beginning of the third quarter.
In 1931 the plague situation was dominated by the conditions in Mid-Java,
but in 1932 the situation in West Java became increasingly serious, and from the
beginning of the second quarter onwards the disease in W est Java, and especially
in Priangan Residency, was the dominant influence in the whole picture. The
maximum mortality was reached in December and was due partly to the increase
of the epidemic in Bandoeng, but also in large measure to the spread of the disease
to Garoet Regency, where it assumed epidemic prevalence in the last quarter of
The introduction of the disease into Garoet itself seems to have been
definitely due to transfer from Bandoeng by the medium of merchandise conveyed
by road. During 1933 the story of the disease in W est Java is practically that
of the whole island. The peak of the 1932 epidemic was carried over till the
early part of January, when it declined. The minimum period which followed
was, however, much higher than in any year since 1914— the peak year of the
epidemic in East Java—and not so prolonged. As early as the end of February
the mortality was again increasing in Garoet Regency, and it is this area which has
been most heavily infected throughout 1933. Both in Bandoeng and in Garoet
there has been the usual definite increase in mortality in the last quarter of the
M A N C H U R IA .
Notification that plague had broken out in Manchuria was confirmed on
September 18th when information was received that the disease had been present
in Tungliao district since the beginning of August, and had spread to a number
of villages to the north-west of Tungliao town. The disease was also found to
be present later in August in villages near Nungan, and in the early part of
September in the Ssupingkai-Taonan Railway zone. These areas constitute
endemic foci in which the disease has been present for some years. Dr. W u Lien-teh
has expressed the opinion that the Tungliao area has been affected endemically
at least since 1924. Subsequent reports showed that the disease continued in these
districts throughout September and October, but began to decline in November.
In the meantime, an outbreak was reported the first week in November from
Jehol district in a village thirty-five miles from Chiehfeng, several hundreds of
deaths being reported during the month. The epidemic was apparently over in
December in all areas and, although it is difficult to determine the extent of the
mortality, which was probably high, there seems little doubt that the disease was
bubonic in form.
U N IO N O F S O U T H AFRICA.
A report for the week ended 7th October states that there was reason to
believe that plague infection in veld rodents had crossed the Oliphants River, in the
district of the Cape Province, where the Health Department has for some years
past been endeavouring to maintain a barrier against plague infection reaching
the wheat-growing area of the Western Province of the Cape. A strategic line
had been selected in order to make use of natural boundaries, such as rivers,
irrigation canals and more or less barren mountain-ridges unsuitable for burrowing
rodents. The first clearance of this belt was completed in May, 1927, following
which appropriate steps were taken according to the species of rodents found to
keep it free. The suspicion that this barrier had been pierced was later confirmed.
In the report issued at the end of June, 1932, by the Department of Public Health,
it had been noted that although no human cases of plague had occurred in the
year in the Cape Province the line of plague rodent infection had almost reached the
banks of the Oliphants River.
Human plague was found on farms in Uitenhage district during
November and also evidence of extensive rodent mortality.
has previously been infected, there being records of infection on farms
as far back as 1916, and again in 1923. In both instances the source of infection
was probably veld rodents. Again, in 1929, veld rodent infection became active
and was the source of several human cases.
S O U T H W EST AFRICA.
The plague outbreak which commenced in Ovamboland in December, 1931,
continues and has been responsible for more than 100 cases in 1933. The mortality,
however, is very low, approximately 5%.
CHOLERA I N PORTS.
Consideration of cholera in Eastern ports in 1933 resolves itself mainly
into a chronicle of events in Calcutta, which, as usual, has been infected throughout
the year. The disease has followed the usual course fairly closely and consequently
has shown a marked tendency to increase in prevalence in the latter half of March,
which tendency is continued sharply throughout the month of April in the last
week of which the peak was reached. During May and June a marked fall in
the number of cases occurred, and, from the middle of June onwards, the disease
has continued, but in endemic form. Compared with the curve showing the
mean for the previous five years, 1933 has shown a higher peak which was
reached about two weeks earlier than that for the quinquennial mean. This
increased incidence has been quite considerable being approximately 25% above
the average for the previous five years.
Among other pcrts of British India, Chittagong has shown a much heavier
incidence than in 1932, but this year’s record, however, compares very favourably
with 1931. The greater proportion of the cases in 1933 occurred in April and
May, although sporadic cases were reported at intervals throughout the year.
Madras, which, during the five years preceding the one under review, was
heavily infected in 1928 and in 1931, was entirely free from the disease from
March 1932 until the last week of October 1933. After this, and until the end
of November, sporadic cases were reported, but at the beginning of December
the disease appeared in epidemic form, but quickly abated, the epidemic prevalence
disappearing by the middle of December.
The other ports of British India from which cases were reported include
Bombay, Moulmein and Rangoon, in each of which sporadic cases only were
recorded. The same condition of affairs prevailed at Vizagapatam, where the
cases were practically confined to the weeks ending July 29th to August 12th.
P H IL IP P IN E ISLANDS.
Cebu notified the first case of cholera for the year in the week ending 24th
June, after an interval free from cases extending back to beginning of September,
1932. The next case was reported in the week ended August 19th, and from
that time onwards a small number of cases was notified each week. From Ilo-Ilo,
on the other hand, only two cases have been reported. A small epidemic occurred
in both of these ports in 1930 when the disease was also presentin Manila;
Manila, however, has been free during the whole of 1933.
Bangkok, notified three sporadic cases at intervals during the first six months
of 1933. The noticeable feature, however, has been the diminution in prevalence
of the disease in the last five years. In 1928 and 1929 the number of deaths
notified was 250. In 1930 only twenty-six deaths were recorded which compares
with eight in 1931 and two in each of the years 1932 and 1933.
IN D O -C H IN A . v
Sporadic cases have
been reported from Pnom-penh and Saigon to the
number of five in the case of the former port and eleven in the case of the
latter, but these were probably not true cholera.
C H IN A .
The most important difference between the returns for 1932 and 1933,
however, is the almost complete absence of cases in Chinese ports. A small number
of suspicious cases has been notified from Hangchow but the only ones which
have been bacteriologically confirmed occurred at Hankow. These comprised two
cases for the week ended July 29th and one for the week ended September 29th.
A very strict watch was kept for the disease in Shanghai, and, although a number
of cases showing clinical symptoms were admitted to hospital, or notified as
suffering from gastro-enteritis, in no case was the disease found to be due to true
CH O L ER A I N C O U N T R IE S .
Cholera has been very light in British India as a whole during 1933.
Compared with the mortality for the preceding five years the disease this year
has caused deaths which are only approximately one-tenth the mean figure of
the preceding quinquennial period. Russell has drawn attention to the tendency
of cholera in India to follow a six-year cycle, but points out that adherence to
this cycle is not necessarily constant, nor does this tendency explain the problems
associated with the epidemiology of the disease.
In many of the provinces—e.g. Bihar and Orissa, United Provinces, Central
Provinces,—the year 1930 showed the highest mortality for the quinquennial period
1928-1932. The year 1930 was also the year of maximum mortality in Bihar and
Orissa, United Provinces and Central Provinces for the six-year period 1925-1930,
whereas Bengal and Madras Presidency reached their peak in 1928, and Bombay
and Punjab in 1927. It is probable that 1933 was at the bottom of the cholera
cycle but the number of deaths has fallen so very rapidly since 1930 as to suggest
that several favourable factors were at work.
The position, compared with 1932, is that cholera
mortality showed over
the whole year a definite rise in Central Provinces and Bombay Presidency and
a definite decrease in Bengal and Madras Presidencies as well as a slight decrease
in Assam and in Bihar and Orissa.
The graph shows that there was the usual tendency towards an
increase of mortality in March, but the mortality, instead of continuing to rise
sharply in April, remained steady for the first three weeks and then
decreased to a minimum in June.
This was followed by a steady rise
throughout August, September and the early part of October, before the fall
commenced later in that month. The explanation of this
variationin the graph
from that of the quinquennial mean is seen when those for individual provinces
In Bihar and Orissa, instead of the mortality rising sharply in
April to its maximum in May, (3,000 deaths in the week for the quinquennial
period) there was only a slightly increased mortality in the first two weeks of
April (120 deaths in the week as a maximum), after which the mortality remained
at a low level until August and September when it rose sharply to reach a peak
in October higher than is usual at this time of the year, but declined rapidly and
remained below the average for the rest of the year.
In Madras the disease was practically non-existent until July when the
mortality commenced to increase, but continued through the following months
at a level lower than the average of the preceding five-year period.
In United Provinces the mortality rose sharply as usual in April, but,
instead of continuing during the succeeding months, fell rapidly in the latter part
of April, and through May, to a June minimum.
The lower mortality from April to September was thus mainly due to the
favourable situation in Bihar and Orissa and United Provinces, together with the
low mortality in Madras.
Bengal:—Russell has shown that cholera has a different periodicity in the
areas lying to the east of the Ganges from that in the areas to the west of it.
This can be distinguished in the mortality returns for 1933. For instance, the
mortality in Decca, Mymensingh and Tippera districts, situated to the east of
the river, reached a maximum in each in March and April and took a larger
share in determining the shape of the curve for the Presidency than did the carry
over of the mortality in the districts to the west of the river. The mortality in
certain of these latter districts, such as Midnapur, Howrah, Parganas, Calcutta
City and Khulna continued to be heavy, however, right up till May. The mortality
from the beginning of June has been below the average this year but the tendency
to a November/December rise, though slight, is evident, particularly in the district
of Mymensingh, adjoining the Sylhet district of Assam.
Assam:—The figures for Assam, on the contrary, are of interest. For the
province, as a whole, the mortality for the first three months of the year was very
low, but increased from the middle of April to the middle of June owing to the
unfavourable situation in Sylhet district. It decreased again, as is usual, during
the monsoon season from June to September, but in October there was an explosive
epidemic causing a mortality many times in excess of the quinquennial average,
which continued throughout November but rapidly declined in December. This
epidemic has been confined to two districts, namely, Cachar, where the peak was
reached in October, during which month occurred the biggest and most widespread
epidemic recorded since 1906, and Sylhet, where the peak of the epidemic occurred
A report by Colonel Morison and others to the Assam Medical Research
Society states that since June, 1932, Habiganj area has been a parallel experiment
to Nowgong, with four sub-divisions of Sylhet, and the District of Cachar as
controls. Bacteriophage had been distributed in Habiganj before the epidemic
but not in the control areas. In the latter, however, vaccination had been pushed.
In the control areas over 5,000 cases with 2,500 deaths occurred while in Habiganj
there were only 108 cases with 4 deaths, despite the fact that this latter area has
been practically encircled by cholera-infected districts.
The authors say that they can find no previous incidence of cholera having
occurred in all other parts of the Surma Valley when Habiganj remained free.
Nowgong District, where bacteriophage has been used to the exclusion of other
preventive measures since 1929, was again conspicuous by its freedom from cholera.
Madras:—The year 1933 has been an extremely favourable one for Madras
in that the cholera mortality has been approximately only one-twenty-fifth of that
for the mean of the quinquennial period preceding it. From February 1932
onwards, the mortality had been very low, and neither the normal increase which
usually occurs from June to August in the northern districts, nor the later rise
in November in the south-eastern districts had taken place. In consequence, the
graph does not show the peak in January which is such a prominent feature of
the graph constructed from the mean mortality figures of the preceding five years.
It was not until July that the mortality commenced to rise in the West
Godavari district, in the northern part of the Presidency. This continued, and
was followed by rising mortality figures in East Godavari district and in Ganjam
district in August and September.
In the Godavari district the mortality has remained small but steady in
October and November but in December there was a definite increase in the
neighbouring districts of Kistna and Guntur. During the months of October and
November there has been some increase also in North Arcot district in the south
east. There has, however, been no general tendency towards commencing epidemic
prevalence in the south-east, as is seasonal towards the end of the year.
Bombay:—Bombay Presidency has had a considerably heavier mortality in
1933 from cholera than in 1932, in which year the usual prevalence from April
to September did not appear at all. In 1933, on the other hand, the mortality
was higher than the quinquennial mean during April and May, but below the
mean figure for the remainder of the year, although the mortality increased
considerably in July to reach its peak in August. It should be mentioned, however,
that there is a considerable difference in the graphs for the mean quinquennial
mortality for Bombay for the periods 1927-1931 and 1928-1932.
includes three years in which the total mortality was above 15,000, whereas the
latter has only two years with a mortality over 15,000, while the third is replaced
by a year where the total mortality was only one-tenth, namely, 1,500.
The shape of the graphs for these periods is also different. In the 19271931 period the mortality rises sharply in March and continues with fluctuations
to a maximum in August, whereas in the 1928-1932 period the mortality remains
low until the beginning of June, after which it increases to reach the maximum
in August. In 1933, the April increase was caused mainly by a sharp explosion
in Ahmednagar District, which rapidly diminished in severity. The mortality in
other districts, however, particularly Sholapur, was increasing in April and May
and contributed to the rise above average figures which took place in these two
months. In July, Sholapur and Ahmednagar districts were again mainly responsible
for the increasing mortality, but in August Satara and Poona, with East and West
Khandesh districts, reached their maximum mortality. The heaviest mortality thus
occurred in the Central Registration district, which included all the districts referred
to except the Khandesh areas which are in the Western Registration district.
Bihar and Orissa-.—The usual increase in mortality from April to September
did not take place in 1933, but instead the mortality commenced to increase in
August, and reached a maximum in October, when a definite decrease occurred.
The increase in August was due mainly to the epidemic which commenced in
that month in Cuttack district in the south, and reached its peak in September.
Bhajalpur district, in the north, had an increasing mortality throughout September,
which reached a maximum in October. The mortality in this district was mainly
responsible for the sharp peak in the curve shown in the graph, although
the mortality in the adjacent northern district of Darbhanga contributed in part
to its production.
United Provinces:—There was a sharp rise in the mortality curve in United
Provinces during April, which was almost entirely caused by an epidemic in the
Basti district. This epidemic was of explosive type, and quickly subsided. A
smaller epidemic in Garakphur district was active in April, but produced its
maximum mortality in May. The mortality for the year has however been less
than 2% of that for 1930, the year of maximum prevalence in the preceding fiveyear period.
The situation in Burma in regard to cholera in 1933 has been extremely
favourable when compared with the mean mortality of the preceding quinquennial
period. The picture for that period is of steady mortality throughout the year
with a maximum in April. During the last quarter of 1932, however, the mortality
was practically non-existent, and this happy state of affairs was continued through
out January and February of 1933. Throughout April, May and June there
was some increase, with maximum figures in July which were much below the
average. From August onwards only sporadic cases have occurred.
As regards rural cholera, Akyab district recorded four deaths in March,
and this was the heaviest mortality in any district for the first four months of the
year. During May there was some mortality in Mergui town which continued
throughout June and July, and during the latter two months the mortality of
Mergui district reached its maximum. It was the situation in this town and
district, together with that in Prome district, that was mainly responsible for the
maximum mortality in July. The only other districts which recorded a noticeable
mortality were Thaton and Amherst, situated north of Mergui in the Tenasserim
district, in the extreme south-east of Burma.
PO RT U G U E SE INDIA.
Cholera has been reported from five areas in Portuguese India during the
year. The more important of these was Ilhas (Nova Goa), where twenty-five
cases with five deaths occurred during August and nine cases with two deaths
P H IL IP P IN E
Cholera, which had recurred in the province of Leyte in December, 1932,
continued to occur during the first five months of 1933. The maximum mortality
was reached in February, and, apart from an exacerbation at the end of April, the
disease steadily diminished from that time.
Samar Province, where cholera was also epidemic at the end of 1932, has
had a recurrence in 1933, commencing from June and continuing subsequently,
although in a lighter form than in the previous year. The provinces of Leyte
and Samar were declared free from epidemic cholera and the inter-island quarantine
measures previously imposed at the ports of entry, because of the prevalence of
cholera on these islands, were withdrawn on the 22nd August 1933.
Behol Province, on the other hand, which did not report any cases of the
disease in either 1931 or 1932, notified a small epidemic in June and a heavier
mortality since October, which reached its maximum in November.
Cebu. Sporadic cases of cholera were reported from Cebu in February,
but it was not until July that the mortality increased to a relatively high figure.
Since this time there have been deaths from the disease in each week. Two other
provinces, Antigue and Occidental Negros, have reported cases at intervals since
June, while from Ilo-Ilo, Occidental Misamis, Pampanga and Rizal Provinces a
single notification has been received.
C H IN A .
There were three mild cases of cholera reported from Peiping during 1933,
one in June and two in August. As none of these three persons had been away
from Peiping the infection was a local one. The clinical history was typical of
cholera and was confirmed bacteriologically in each case. Although one of the
patients was a waiter in a well-known restaurant, no spread took place.
The early part of 1932 was particularly notable for the epidemic prevalence
of smallpox throughout Eastern ports.
Between Alexandria in the Near East and Hong Kong in the Far East
many ports recorded a greatly increased prevalence of the disease as compared
with the records of the preceding five years. In Alexandria the epidemic which
commenced in December 1932 increased steadily in January, to reach a peak in
the early part of February 1933. The epidemic prevalence fell sharply throughout
the remainder of February and through March, and was completely finished in
B RITISH IN D IA .
In British India the incidence differed very considerably in Karachi as
compared with Bombay. In Karachi the number of cases reported rose gradually
through January and February, and more sharply throughout March, to a peak
at the beginning of April. The decline was gradual and the epidemic was not
over until July.
In Bombay, on the other hand, the rise in the number of cases commenced
in December 1932 and continued sharply throughout January and the first half
of February, to reach its maximum at that period. Here, again, the decline was
somewhat slow, and it was the middle of May before the epidemic ceased. The
number of cases recorded was 4,500 with 2,375 deaths. Smallpox is always present
in both of these ports, but the case and mortality rates have this year been many
times in excess of the mean of the previous five years.
In Calcutta, where the epidemic months were the same as those in Bombay,
the case incidence was even higher, 5,684 cases being notified, with more than 4,000
deaths. In none of the preceding five years did the number of deaths recorded
come within 50% of this figure.
Madras:—A different picture can be drawn from the figures recorded for
Madras, where the epidemic, although following a similar course to that in Bombay
and Calcutta, did not subside so completely in May, although a minimum was
reached early in June. Following this the number of cases increased again, and
remained high throughout July, August and September, finally falling through
October to an absolute minimum for the year in November. The number of
deaths in Madras, as in the other ports mentioned, was greatly in excess of that
recorded in any of the previous five years.
Rangoon:—In contrast to the ports just mentioned, Rangoon, which had
been the scene of a severe epidemic in February and March, 1932, received only
a mild visitation in 1933, when the number of deaths was considerably lower than
the average annual number recorded for the previous five years.
Smallpox was present also in other ports of British India but not in
O T H ER PORTS.
Colombo:—Colombo showed an increased prevalence of smallpox in
December, 1932, which was continued into 1933. The disease was under control,
however, by the middle of February, sporadic cases only being notified during the
remainder of the year.
C H IN A .
Hong Kong, following a period of several months’ freedom from notified
cases, recorded smallpox in epidemic form in the months of January to April,
with the peak of the curve at the end of February.
In Canton, on the other hand, an explosive epidemic commenced in December,
reached its height at the beginning of January and was over by the end of February.
O f the other Chinese ports, Nanking showed
epidemic prevalence of the disease, with the peak in the
Shanghai, on the other hand, although not showing the
has recorded a small number of cases each week and
the nearest approach to
second week of February.
disease in epidemic form,
has remained endemically
Chemulpo:—In the Korean Peninsula smallpox occurred in epidemic form
during February and March in Chemulpo, and from that time until the end of
August a small number of cases was reported each week.
Fusan:—During April, May and June a small number of cases was also
reported each week from Fusan, but none since the middle of July. There had
previously only been sporadic cases in 1927, 1928 and 1930, and none occurred in
1931 or 1932.
A noticeable feature of the returns is the almost complete absence of cases
from certain ports of British India, e.g. Chittagong, Moulmein and Tuticorin.
The records of the previous five years show that cases are rarely recorded in
Chittagong, but Moulmein had in 1928, 1929 and 1930 small epidemics, while
Tuticorin was visited similarly in 1932.
The ports of Singapore and Batavia have recorded only one isolated case
each, while Bangkok, as well as ports of French Indo-China, have recorded sporadic
C O U N T R IE S.
The year 1933 has been an unfavourable smallpox year in British India,
and this fact was seen very early in the year when the high incidence which had
developed in the last quarter of 1932 was continued. The peak was reached in
April, being a little later than had been the average for the preceding five years.
The normal sharp decrease in numbers took place in May and June, with the
onset of the south-west monsoon, and this has continued through the succeeding
months until October, when an increase commenced.
The mortality in most of the provinces has been higher in 1933 than in
1932, and particularly has this been the case in Delhi, Bengal, Bombay
and Bihar and Orissa.
Delhi:—In Delhi the number of deaths recorded has exceeded the number
in any of the preceding five years. The majority of the cases and deaths
occurred in Delhi City where the mortality continued to be heavy throughout
January, February and March.
Bihar and Orissa:—In Bihar and Orissa the number of cases has throughout
exceeded the mean of the preceding five years. The peak period was reached in
April, when the number of cases, as well as the mortality, were many times in
excess of the average (approximately 20,000 cases and 4,500 deaths as compared
with 5,500 cases and 1,100 deaths). But, in addition to this maximum mortality
in April, there has not been any weekly period during the year when the incidence
and the mortality have not been much in excess of the average figures for the
preceding five years. The year 1933 has also recorded a higher mortality from
smallpox in this province than has been the case in any of the preceding five years
and returns show that the mortality has been steadily increasing since 1929. A
detailed analysis of the districts shows that the disease has been prevalent through
out, but Cuttack and Puri districts in the south and Gaya district in the north
were noticeably affected. The curve for this province will be seen, on comparison
with that of British India, to present the same features, and it has probably been
responsible in large part for the general trend of the curve for the country.
Bombay:—Bombay has returned this year a mortality from smallpox which
is more than double that of 1932. This Presidency was, however, much more
seriously affected in the years 1929 and 1930. The curve is somewhat different
from that for Bihar, in that it rises more steadily through the months of January,
February and March, to a maximum towards the end of April. The sharp decrease
at the beginning of May is also very noticeable.
Bengal:—The mortality in Bengal is somewhat heavier than that for 1931
or 1932, but compares very favourably with that of the mortality for the years
1928 and 1930 inclusive. For this reason there is not such a disparity between
the curve for 1933 and that constructed from the mean figures for the preceding
five years. There is, however, a much sharper rise both in the number of cases
and in the mortality figures in February than is usual, but from this period till
the maximum was reached in April the increase is much more gradual. In this
province, as in the others, there is a sharp decrease which is continued throughout
the south-west monsoon period. A more detailed analysis of the figures for 1933
shows that Calcutta City and Burdwan province were responsible for the heaviest
Central Provinces:—By contrast with these provinces the situation in Central
Provinces and Berar has been more favourable than in any of the preceding
five years. Both the curve for cases and for mortality, but particularly the former,
illustrate this and show that, while the number of cases has increased sharply
during April and May, the mortality figure has shown only a slight seasonal
increase, but in each case the increase has been much below the average.
North-W est Frontier Province:—The situation in North-West Frontier Pro
vince deserves notice because of the tendency for the death rate to increase in
May, which culminated in a sharp rise during the middle of June, when 119
deaths were reported as compared with an average of five during this period in
the preceding five years. This epidemic period was of short duration, however,
and by the middle of August the mortality figure had reached a minimum which
corresponded closely with the average at that time for the preceding five years.
Apart from a further short epidemic period the mortality remained about the
General:—Rogers, when stating that the correctness of his forecast of
smallpox in 1933 had been disappointing, suggests that the increased incidence
is partly due to the accumulation of susceptible people. He goes on to say that,
on tabulating the variations of the saturation deficiencies in the monsoon and
autumn months of 1932, and also those of his other forecast years, he found that
"the readings for 1932 were extremely high in just those areas which have shown
the greatest increase of smallpox in the current year, but the autumn saturation
deficiency readings were low in the Central Provinces alone with low recent small
pox in that area only this year. High readings of the 1932 autumn saturation
deficiencies also occurred in the United Provinces, and they were most exceptionally
so in Bihar, with the highest smallpox incidence in 1933.” Rogers thinks this
climatic factor may be of greater prognostic value than the absolute humidity
figures hitherto used.
The outbreak of smallpox which occurred in Colombo in November, 1932,
extended to other parts of Ceylon in December and the following months. In
the period November 30th, 1932, to February 28th, 1933, there were reported in
the whole island 345 cases with 72 deaths—a case mortality rate of 20.9%. The
source of infection was in Colombo in 274 of these cases, the remainder being
infected locally in one or other of the seven provinces in which cases occurred. A
concealed focus was later discovered in April in Galle Municipality and some
adjoining hamlets in the Southern Province. Here forty-eight cases were reported,
the last case occurring on May 2nd. This focus was caused by a case which
had been infected in Colombo during the preceding epidemic.
a house to house search for cases in the infected area was carried
out, cases found were isolated, contacts were vaccinated and segregated
for fifteen days.
An energetic mass vaccination campaign was carried out which in
Colombo accounted for more than the number of the population,
the excess being due to people residing outside coming in for
All unprotected persons attending pilgrimages and religious festivals
in Ceylon were vaccinated.
All unprotected persons leaving Ceylon from the ports of Colombo,
Jaffna and Talaimannar were vaccinated, as were also all persons
visiting ships in Colombo Harbour, and all harbour personnel and
The clothing and personal effects of third-class and deck passengers
leaving Colombo were disinfected.
CH O SE N .
Smallpox was formerly prevalent more or less throughout the year. This
was mainly because of the time-honoured superstition among natives which resulted
in no protective measures being taken. In 1895 the Korean Government made an
attempt to enforce general vaccination, and vaccination regulations were issued.
The results obtained, however, were poor, and numerous cases of the disease were
still reported each year. Later, further efforts were made to combat the disease,
and the services of the police and sanitary officials were enlisted to educate the
people on the prophylactic value of vaccination. At the same time large quantities
of vaccine were distributed free, and female vaccinators were specially engaged to
vaccinate the women. As a consequence, after 1913, smallpox incidence fell to
between 50 and 300 cases a year. In the spring of 1919, however, the disease again
broke out, producing upwards of 2,000 cases. In 1920, malignant smallpox
invaded the country from adjacent territory and vaccination was at once enforced
to the greatest possible extent; nevertheless, out of 11,500 cases there were no
fewer than 3,500 deaths. In 1921, cases still reached the large total of over
8,300, of which 2,500 were fatal, but during 1922, though the disease threatened to
become prevalent in the spring, the authorities were able to hold it in check compared
with the preceding year. For the year 1923, 3,722 cases of smallpox were recorded,
but since that year the disease has gradually declined, until in 1930 1,418 cases
with 323 deaths were reported, while in 1931 there were 1,376 cases with 343
deaths. In 1932, however, the incidence again rose, and the total cases for the
year numbered 2, 707, of which 544 were fatal. These figures, however, compare
favourably with the total of 4,923 cases and 964 deaths which were recorded for
the first thirty-six weeks of the year 1933.
Distribution of the Disease:—The peninsula of Chosen juts out into the
western Pacific Ocean and its coastline can be roughly divided into East, South and
West coasts. The eastern portion of the country faces the Sea of Japan and
comprises three Prefectures, with a population of 3,597,257. The southern portion is
divided into seven Prefectures, this being the most densely populated, with 12,377,601
inhabitants, and the western portion faces the Yellow Sea, comprising three Pre
fectures with a population of 4,288,100. The southern portion is the area of most
interest from the point of view of international trade connections as it includes
the two most important seaports, Fusan and Jinsen, and Keijo, the capital of
The following table shows that the present smallpox epidemic was at first
most prevalent in the eastern portion, subsequently invading the southern
Prefectures, while the western district has also been severely affected since the
beginning of 1933.
or Sea port
1933 (to 5ep. 30th)
(% the year 1933)
Smallpox in Chosen is as rule most prevalent during the spring, i.e. the
months of February, March, April and May, and a sharp fall in the morbidity
curve usually takes place during July/August, after which the curve remains low
until the first week in December, when the disease shows signs of becoming
severe again every year.
The monthly returns of smallpox cases and deaths during the past four
years are as follows:—
3 Years’ Total
Cases Deaths Cases Deaths Cases Deaths Cases Deaths Cases Deaths
A p ril
% the year
Y E A R LY T O T A L
From the above table it will be seen that the figure for deaths from smallpox
during the first three-quarters of the year 1933 was almost as large as the total
number of cases reported during the same period in the past three years, and
that the usual seasonal incidence of the disease was maintained. The months of
July and August are the hot wet months of the year.
I n f e c t e d S h ip s .
During the year a communication was received from the President of the
Sanitary, Maritime and Quarantine Board of Egypt, drawing attention to the
failure of the Bureau to notify the fact that two infected ships which had arrived
at ports in British India had subsequently proceeded towards Europe. The rea
son for this failure was the fact that the Bureau itself had not been notified of the
circumstances. Enquiry showed, however, that, in both cases, the quarantine
authorities of the Suez Canal had been notified directly from the port at which
the infected ships had called in British India. The previous arrangement with
the Public Health Commissioner with the Government of India, by which either
the next port of call or the Eastern Bureau would be notified in the case of
infected ships arriving at British India ports, although in operation, had not met
the situation because it had apparently been applied only to vessels proceeding
to the East. The President of the Board pointed out that, as the Alexandria
Bureau did not receive notification of these vessels, it in turn failed to advise
the Office International in Paris, and, in consequence, one of the ships landed
passengers in Marseilles, some of whom proceeded to Great Britain overland
before the existence of the disease was discovered. Alternative suggestions were
made to the Public Health Commissioner with the Government of India: (1) that
the existing arrangement should be interpreted literally, and the Eastern Bureau
informed by cable of the arrival at ports of British India of infected vessels
proceeding westward, as well as eastward; (2) that the port health officers be
instructed to notify the Alexandria Bureau directly in the case of an infected
vessel arriving at a port and proceeding westward. In his reply, the Public Health
Commissioner advised that the arrangement already in force was intended to be
interpreted literally, and that he had issued special instructions to Port Health
Officers asking them carefully to carry out the instructions as laid down. The
effect of this, therefore, is that the Bureau would receive information of the arrival
at any port in British India of an infected vessel, and so be enabled not only
to notify the Health Administrations at subsequent ports of call but also the
Alexandria Bureau of vessels proceeding towards ports of Europe. The President
of the Sanitary, Maritime and Quarantine Board of Egypt has intimated that
this arrangement should be satisfactory and prevent the occurrence of similar
difficulties in future.
PARTICULARS O F INFECTED SHIPS.
Smallpox:—The prevalence of smallpox in ports of the Eastern zone has
been reflected in the returns received of infected ships. On no less than thirtyseven (37) occasions ships infected with this disease have arrived at ports in
communication with the Bureau. The arrival of these vessels took place in the
following months: in January, seven; February, nine; March, six; April, three;
May, three; August, two; September, two; November, one; December, four. As
might be expected, the source of infection could be traced to ports in British
India in some instances—namely, in sixteen of these vessels. As is usual also
on ships, the extent of the disease was limited, one case only being reported
from twenty-nine of the vessels.
Chickenpox:—Forty-three (43) vessels were reported as infected with
chickenpox, of which twenty-four (24) were infected in ports of British India.
Multiple cases were somewhat more common than in the case of smallpox-infected
ships, but not to such an extent as to constitute a distinction of importance.
Cholera:—F oul (4) ships only were reported to be infected with cholera,
each of which had one case only. In each case the notification came from a
port in British India.
Plague:—No notifications of ships infected with plague were received from
Typhus:—A fatal case of typhus occurred on a vessel which arrived at
Bombay towards the end of May. This passenger had been infected before
leaving Shanghai where he resided.
Influenza:—Two (2) ships were reported on which epidemics of influenza
had occurred. Both were infected at ports in Great Britain and the epidemics
in each vessel had spent themselves before arrival in Bombay and Colombo.
Measles:—Twelve (12) ships had cases of measles on board during their
voyage, but on only one was there an epidemic of serious proportions. This
occurred on a vessel carrying emigrant's from Japan to South America and was
present on arrival at Durban.
Scarlet Fever:—Five (5) ships had cases of scarlet fever on board on
arrival at Eastern ports during the year. One of these vessels had two cases but
each of the others had an isolated case only.
Mumps:—Three (3) vessels were reported to have had mumps on board.
Two of these came from African ports and one from Great Britain.
P il g r im a g e .
The pilgrimage was declared open on January 5th, 1933. The number of
ships departing for Jeddah carrying pilgrims in regard to which notification was
received at the Bureau was as follows:—
„ Straits Settlements . .
„ Dutch East Indies
5 ships carrying 2,365 pilgrims
It will thus be seen that the total number of pilgrims was slightly less than
that for 1932, which figure showed a very great decrease over that for previous years.
The number of pilgrims returning from Jeddah in a year does not necessarily
correspond with those who embark during the same year; returns show that:
Dutch East Indies
10 vessels returned 3,144 pilgrims
All pilgrims embarking from ports of British India for Jeddah are medically
examined before departure, vaccinated against smallpox, unless satisfactory evidence
as to immunity is produced, and inoculated against cholera. The same procedure
applies to departures from Straits Settlements and Dutch East Indies, but,
in addition, pilgrims departing from the latter country are inoculated against
typhoid and dysentery.
The pilgrimage was declared by the Sanitary, Maritime and Quarantine
Board of Egypt to be "clean,” and no cases of cholera or smallpox were reported
from ships carrying returning pilgrims. The only cases of communicable disease
which were notified were five cases of chickenpox on board one vessel carrying
returning pilgrims to British India. The cases were of a mild nature and the
patients were convalescent on arrival at Karachi.
a g a in s t
g a in s t
I n t r o d u c t io n
is e a s e .
plag u e.
Bombay, Rangoon, Colombo. The presence of plague in endemic
form in these ports has resulted in the continued application throughout 1933
of the measures against them which were imposed by the Dutch East Indies in
1913, 1914 and 1928 respectively. The measures prescribe that any vessel which
has in the preceding three months called at any plague-infected port can only
obtain pratique at ports in Dutch East Indies of the first and second class which
are equipped with an apparatus for dératisation—so called "qualified ports”, namely,
Tandjong-Priok (Batavia), Sourabaia, Makassar, Balikpapan, Menado, P. Samboe,
Balawan, Sabang and Padang. At these ports fumigation with sulphur dioxide
by Clayton or Hailey apparatus is carried out before the cargo is unloaded, unless
the vessel after loading was deratised before or after leaving the plague-infected
port, or unless the master can produce the following certificates:
that the vessel was deratised or exempted in a "qualified” foreign
or Dutch East Indies port within a specific period, namely six months,
according to the Paris Convention, 1926;
that in the plague-infected port the vessel has, if possible, not been
moored at the quay and has taken the usual preventive measures against
rat infestation from the shore, e.g. use of ratguards upon all the
connections with the shore or with lighters, gangways etc., which are
well lighted at night;
that the vessel in the plague-infected port did not take any consider
able amount of rat-attracting cargo which was not deratised
immediately before loading such cargo in the ship.
In a qualified Dutch East Indies port, ships arriving from a plagueinfected port under these conditions as a rule obtain free pratique and no
fumigation is ordered. In dubious cases general conditions on board the
ship, e.g. signs of rat infestation, ratproofing, cleanliness, etc., will be taken into
consideration in deciding whether fumigation is necessary or not.
(b) All ships coming from Bombay, Rangoon or other plague-infected port
are fumigated at their first port of call in Japan before the cargo is unloaded.
The fumigant used is carbon monoxide-dioxide mixture generated by the incomplete
combustion of coke. An exception is made in the case of vessels from Dutch
East Indies ports, provided they carry an official certificate showing that dératisation
was performed after loading and just prior to departure.
(c) Persia instituted protective measures against plague from Bombay on
March 4th, and these remained in force at the end of the year.
(d) During the year the Dutch East Indies imposed measures against the
introduction of plague from Pnom-penh (May 27th) and from Baghdad (July
8th) which remained in force at the end of the year.
(e) The Dutch East Indies declared Singapore infected with plague on
the 29th April, 1933. The effect of this was to bring automatically into force
the "Samboe facilities arrangement” under which all vessels from Singapore pro
ceeding to one or other unqualified ports of Dutch East Indies (i.e. small ports
of 2nd, 3rd or 4th class) must first call at Poeloe Samboe for Quarantine
examination. This consists of (1) Medical inspection of crew and deck passengers;
(2) Inspection of the ship; (3) Inspection of the dératisation certificates.
Dératisation was carried out if considered necessary but, in general, a valid
certificate issued one, two or three months previously, accompanied by a statement
that precautions had been taken, was sufficient.
AGAINST CHO LERA.
Bombay. On July 22nd the Dutch East Indies notified that Bombay
had been declared infected with cholera.
On September 28th information was received from the Chief Health Officer,
Baghdad, to the effect that Iraq required deck passengers from Bombay to be
inoculated twice against cholera.
(b) Madras. On December 8th, Madras was declared infected with cholera
by Straits Settlements, Federated Malay States and Dutch East Indies, and this
still remained in force at the end of the year.
(c) Cebu. This port was declared infected with cholera by Dutch East
Indies on October 13th and by Straits Settlements on the 19th October. The
notification was withdrawn, however, by Straits Settlements on the 15th November,
1933, and by Dutch East Indies on the 12th January, 1934.
(d) Chittagong was also declared infected by both Dutch East Indies
and Straits Settlements on April 29th and on May 19th respectively, but the
notification was withdrawn on August 12th and July 28th respectively.
(e) Moulmein was declared infected by Straits Settlements on June 23rd
and this was withdrawn on July 28th.
The effect of the notification çf a port as cholera-infected by Dutch East
Indies is that vessels arriving therefrom within twenty-one days are subject tm
inoculation againff.tUa Hinnir, pairfiarmad aithor at tho inkctod po»t of dopairtwra
to medical inspection, and all passengers are required to produce certificates of
inoculation against the disease, performed either at the infected port of departure
or during the voyage. Those who cannot do so are inoculated forthwith. If no
cases are found, crew and passengers are kept under surveillance for five days from
date of departure from the infected port, but during this period the ship may
proceed under surveillance to other ports. The excreta of crew and passengers
under surveillance must not be emptied into the waters of the port without
In the case of Straits Settlements, the declaration results in the quarantine
examination of vessels from the infected port to determine if cases are present. If
not, all deck passengers arriving within five days of leaving the infected port are
sent to the Quarantine Station at the port of disembarkation and detained for the
balance of the incubation period. Cabin passengers are released under surveil
Vessels arriving in Hong Kong from ports declared infected with cholera
undergo quarantine inspection. If no case is present, but five days have not
elapsed since leaving the infected port, through deck passengers are not allowed
to land and hawkers are not permitted on board. If more than five days have
elapsed no special action is taken.
Vessels arriving at Saigon from ports declared infected with cholera are
inspected and, if no cases are found, all deck passengers are inoculated against the
disease unless this procedure was carried out either at the port of departure or
during the voyage. If the voyage is of shorter duration than five days these
passengers are kept under surveillance until the five day period has passed.
Japanese ports:—The crew and passengers of vessels arriving from ports
declared infected with cholera have their stools examined for presence of cholera
vibrios at the first port of call in Japan. They are allowed to continue the journey
under surveillance and the result is telegraphed to the next port of call, where
any necessary action is taken.
Passengers from cholera-infected ports within a few days’ steam of
Manila must be inoculated before departure;
The crew and passengers of vessels arriving in Manila after a journey
of more than five days from a cholera-infected port have their stools
examined on arrival. Cabin passengers with a definite address are
allowed to land immediately, but steerage passengers are detained on
board for the twelve/twenty-four hours that elapse till results of the
examination are known.
Owing to the prevalence of smallpox, many ports were notified by various
countries as being infected. The measures imposed against such ports varied e.g.
Iraq required all deck passengers from India to produce certificates showing that
they had been vaccinated against smallpox during the preceding three years or to
show marks of recent successful vaccination.
Philippine Islands, on the other hand, required passengers from ports
declared infected with smallpox, and who are destined to disembark, to produce
acceptable evidence of vaccination against smallpox within a year, or to be
vaccinated before embarkation.
The procedure in Straits Settlements depends on the action taken in the ports
of embarkation. For example, deck passengers from British India and China are
vaccinated before departure, and are landed at the Quarantine Station on arrival
at ports in Straits Settlements for disinfection and re-vaccination of those who
have not had successful takes. Deck passengers from other smallpox-infected
ports are landed at the Quarantine Station, vaccinated, and detained for four
days. Any whose vaccination has not taken are re-vaccinated, but these are all
released on the fifth day.
French Indo-China:—Deck pasengers are medically examined and re-vaccinated if evidence of successful vaccination before departure from the infected port
is not forthcoming.
LIST O F N O TIFICATION S.
A list of quarantine notifications imposed during the year, together with a
list of such notifications still in force on January 1st, 1934, will be found in
rogram m e.
Dr. H irst’s contributions to the study of plague epidemiology have been
further added during the year by the publication of the results of "A Rat-Flea
Survey of Ceylon” which contains also "A Brief Discussion of Recent Work on
Rat-Flea Species Distribution in relation to the Spread of Bubonic Plague in the
East Indies.” The author expresses the view that the conclusion reached by King
and Pandit that ''the flea species factor is of the first importance in the spread of
plague” in South India applies equally well to Ceylon.
China:—The rat-flea survey at Shanghai has been continued throughout
the year. O f the two prevailing species of rats, R. Rattus and Rattus Norvégiens,
the former was many times more numerous than the latter throughout the period.
The highest flea index was recorded in the month of May, but relatively high
figures were also recorded in October, April and December. Leptopsylla Musculi
was the prevailing species, but the presence of Ceratophyllus Anisus was also
detertmined regularly, with a maximum index in April and May. X. Cheopis
was absent during March, April and June and only a few of the species were
found in January, February and May. The index, however, which was .01 in
May and .00 in June was .1 in July, .75 in August, .3 in September and .59 in
October. The rise in August was more noticeable in that X. Cheopis was practically
the only flea species present during the month. During July and August the
mean temperature was 83.7°F. with a mean relative humidity of 82.3 in July and
79 in August. The rainfall was just over two inches in July, but in August
was 5.4 inches.
Asheshov, in his report for 1932-33 on the Bacteriophage Enquiry, states
that he has "chosen the problems to be studied in such a way that the results
obtained might directly help the practical application of bacteriophage.” Some
of these problems deal with the results of cultivation on vegetable and synthetic
media, the influence of hyperaerobic conditions on virulence, the preparation of
pure choleraphage antigens free from vibrio substance, the degree of absorption
of choleraphage, the influence of carbohydrates and the development of choleraphage,
and the continuation of the search for choleraphage races which are at the same
time virulent against the common intestinal bacteria.
The biological nature of bacteriophages has been the subject of discussion
by Burnet and others. The former concludes:
that bacteriophages are independent microorganisms, viruses which,
are obligate parasites or symbionts of bacteria, and
that there are many different types of bacteriophage which may differ
widely in particle size, as well as in almost every activity by which
a phage can be characterised.
Andrews and Elford, using filtration methods, have calculated the physical
measurements of bacteriophages and find the diameter of the smallest one yet
examined identical with that found by the same methods for virus of foot and
mouth disease. The size of any one bacteriophage has been found to be remarkably
constant and uniform, independently of the nature of the bacterial organism which
it attacks, and it is unchanged by purification (Report of Medical Research Council,
Shanghai:—Investigations carried out during the year in Shanghai indicated
that practically all samples of "non-waterworks” water examined, i.e. water from
river, creeks, ponds and wells, contained non-agglutinating water vibrios. Experi
mental work is being carried out to determine what happens when true cholera
vibrios, water vibrios and mixtures of both are added to water of various kinds.
W ater vibrios are being grouped according to the scheme established by Finkelstein,
and interest is naturally centred on the degree of relationship, if any, which exists
between the different groups of vibrios.
Bacteriophage:—Evidence of choleraphage was found in two river
and four creek samples examined.
Carriers:—N o carriers were found among over 500 specimens of
stools examined from hospital in-patients.
Meteorology:—A great deal of meteorological data has been obtained,
and from an analysis of this it is possible to show that, in the last seven
years, high absolute humidity favours cholera epidemics, but is not always
followed by them. Charts from a number of ports showed that cholera
only became epidemic when the absolute humidity was above 0.4 in. (cf.
Rogers). Deficient winter and/or spring rainfall is apt to be followed by
an outbreak of cholera, whereas heavy rainfall appears to have the opposite
effect. As the spring of 1933 had a high rainfall, the conditions seemed
favourable for a light cholera year, which was actually the case.
Cyclical Tendency:—A study of cholera epidemics in Shanghai has
also suggested an indefinite four-yearly epidemic cycle.
Calcutta:—Linton’s further work in Calcutta tends to establish a closer
relationship between water vibrios and true cholera vibrios. Previously it had
been thought that water vibrios were distinguishable by having an arabinose con
taining carbohydrate, while pathogenic forms had a galactose containing substance.
This is not now found to be a distinction in that two strains from clinical cases
of cholera have been found to be arabinose-containing.
Pasticha, de Monte and Gupta have produced experimental evidence that,
in regions like Calcutta where cholera is endemic, there exist bacteriophages under
the influence of which in the laboratory certain strains of atypical non-agglutinating
vibrios can acquire the property of agglutination with cholera specific serum.
They conclude that vibriophages play an important part in the epidemiology
of cholera and that they are one of the important factors in bringing about a
regeneration of degenerated cholera vibrios.
L ia is o n
d o c u m e n t a t io n
w it h
d m in is t r a t io n s .
The following documents have been received and distributed to Health
Administrations and interested workers:
Quarterly Bulletin of the Health Organisation, Vol. I, No. 4, and
Vol. II, Nos. 1, 2 and 3.
Articles on special subjects received from the Health Organisation.
"L’Epidemiologie du Choléra au Hedjaz”—by W . Doorenbos.
“Preservation of Viability and Virulence in Dried Pathogenic Bacteria
"Dead Vaccine”—by L. Otten.
"Dry Lymph”—by L. Otten.
"Mitsuda’s Skin Reaction and Leprosy Classification”—by Fumio
"The Prevalent Condition due to each Bacterial Type of Typhoid
Bacilli and its Epidemiological Observation”—by K. Shimojo.
"A Rat-Flea Survey of Ceylon with a Brief Discussion on Recent Work
on Rat-Flea Species Distribution in Relation to the Spread of
Bubonic Plague in the East Indies”—by L. Fabian Hirst.
A short visit was paid to China in October and November and the opportu
nity taken of becoming familiar with the developments in the National Health
Administration. This Administration is now housed in the recently constructed
premises of the Central Field Health Station, which together with the General
Hospital adjoining forms a worthy monument to the interest and enthusiasm of the
Director of the Administration, Dr. J. Heng Liu.
At Peiping the work of the health stations organised by the Public Health
Department of the Peiping Union Medical College was studied, and additional
information was obtained from Dr. C. C. Chen on the rural hygiene experiment
in Ting Hsien.
In Amoy and Shanghai much information of interest was found by looking
into the details of the working and development of the National Quarantine Ser
vice. In the former port the Quarantine Station now possesses additional hospital
accommodation constructed in such a way as to serve the needs of all classes of
the population at such times as epidemic diseases prevail.
The data and experimental work on cholera carried out under the auspices
of the Cholera Bureau at Shanghai form the nucleus of a much needed investiga
tion into this subject, and could with advantage be extended further afield.
An account of the working of the Health Department of Greater Shanghai
was obtained from the Commissioner and a visit was paid to the Woosung Health
Centre, and subsequently to the teaching health centre of Kao Chiao.
Through the kindness of the Acting Commissioner of Public Health and
the Director of the Lester Institute, visits were paid to the recently constructed
public abattoirs of the Shanghai Municipal Council and to the Institute.
A t Hong Kong the Director of Medical and Sanitary Services personally
arranged a tour of the New Territories to see the organisation of health centres.
In December a most instructive week was spent in the Dutch East
Indies, where the Director of Public Health Services had kindly arranged for a
visit to be paid to one of the plague-infected areas to see the work of house renova
tion in progress. Some days were also spent in an investigation of the work in
rural districts which is being carried on under the supervision of the representative
of the International Health Division of the Rockefeller Foundation.
The proposal to establish international malaria courses with headquarters at
Singapore having been adopted, the Principal of the Medical College, with the
approval of the Government of the Straits Settlements, has arranged a programme
for the laboratory and theoretical study for the first course which will commence
on the 30th April, 1934. A full programme of lectures and laboratory instruction
has been drawn up, and among the lecturers will be professors attached to the
Medical College and members of the profession who have made special contributions
to the subject of malaria. Invitations have been accepted by Professor E. Walch,
Director of the Geneeskundige Hoogeschool, Batavia, and Dr. H . Morin, Director
of the Anti-Malaria Service in French Indo-China, to co-operate in the theoretical
course, and both of these experts will deliver lectures at Singapore. In addition,
the Secretary of the Malaria Commission, Professor Ciuca, will come to Singapore
to participate not only in the actual instruction to be given at the Medical College
but also in the final arrangements which will precede the course. It will be
remembered that the whole of the initiative in regard to the establishment of these
courses has been taken by Professor Ciuca, who had established contacts with the
health authorities in several Eastern countries during his tour in 1932. Through
the courtesy of the Health Administrations of Indo-China, the Netherlands East
Indies and Straits Settlements, field courses are being arranged in each of these
countries. They will extend over a period of twenty-one to twenty-five days, during
which time an intensive course will be carried out which will enable candidates to
take part in the practical application of the methods of control which are used
in each of the areas to be visited. It is proposed that candidates should be divided
into three groups, each of which would carry out a course of field study in a
country where the problems are similar to those which the candidates will be
required to deal with on their return to their own countries.
Organisation has offered six fellowships to Eastern countries on condition that the
acceptance of a fellowship involves the obligation to send an additional candidate
at the expense of the country concerned. China, Straits Settlements, Australia,
Siam, French Indo-China and Japan, to whom the offers were made, have indicated
their acceptance. In addition to these candidates, it is anticipated that
approximately eight to ten will attend the course from Malaya itself. A number
of enquiries has been received from medical practitioners in British India, and it
is possible also that one or two candidates from this country may attend as well.
It is evident that the course is arousing considerable interest, which has been
stimulated by the courtesy of the editors of medical journals in Japan, China,
Malaya, British India, Siam and Dutch East Indies, in publishing information
regarding it supplied to them by the Bureau. It must be confessed, however, that
the expense which is entailed, particularly in regard to carrying out field courses,
is considerable, and the effect of this may need to be taken into consideration in
In accordance with the resolution adopted by the Advisory
Council, the progress of the first course will be carefully considered, in consultation
with the authorities concerned, in order that the experience gained may be used
in the campaign against malaria in every country.
The Bureau, acting on behalf of the Health Organisation, has arranged
study tours during the year for Dr. Vidhivejj of Siam and Dr. Anklesaria of
Rangoon. Dr. Vidhivejj proceeded via Japan to the United States, where he
made a short intensive study of quarantine methods in New York, New Orleans,
Baltimore and San Francisco. The arrangements for this tour were very kindly
made by Surgeon-General Gumming and Dr. Carmelia, and resulted in Dr.
Vidhivejj obtaining—in his own words—a very valuable addition to his knowledge
Dr. Anklesaria, who holds the position of Port Health Officer in Rangoon,
was enabled to make a study, principally of quarantine procedure, at Penang,
Singapore, Hong Kong, Shanghai, Japanese ports and Manila. That he was
enabled to obtain the utmost benefit from his visits to these places was due entirely
to the completeness of the arrangements made for him by the health authorities,
who not only made him welcome, but went to very much trouble to ensure that he
became acquainted with all the details of their work. Dr. Anklesaria on his return
prepared a detailed report, which showed that his time had been well spent and that
he had been enabled to accumulate a great deal of experience from the tour. An
official letter of thanks was received from the Government of Rangoon for the
Introductions were also given to Dr. Scharff, Senior Health Officer for
Penang, who was passing through Japan on his return for duty with the Government
of the Straits Settlements. Dr. Scharff has expressed his appreciation of the manner
in which he was received in Japan, where every opportunity was given him in his
desire to study Japanese methods of health administration, particularly in regard
h y g ie n e .
The delegates of various countries who attended the meeting of the Advisory
Council undertook to supply to the Bureau information regarding rural hygiene
in their countries. A great deal of information with regard to this matter has
since been received from the Dutch East Indies, Hong Kong, Straits Settlements,
Philippine Islands, British North Borneo, Japan, Ceylon and Rangoon, and,
in addition, information is being collected regarding the work being carried out in
certain parts of China. During the ensuing months it is hoped that the document
ation will be fairly complete, after which an attempt will be made to collate the
information in such a way that it can form the basis for a conference on Rural
Hygiene, to be held at an appropriate time. Should it be possible to hold an
informal meeting during the time that the Far Eastern Association of Tropical
Medicine meets in Nanking in October, 1934, this preliminary information can
be circulated and discussed by representatives of the various Eastern countries
in a n c e .
During 1933 all expenditure in connection with the Bureau was carefully
scrutinised, with the result that the year has finished with a balance in hand which
has been added to the working capital fund. The most encouraging feature in
the financial situation has been the continued support received from certain Eastern
countries. Every country from which contributions have been received in previous
years, i.e. Japan, Philippine Islands, Hong Kong, French Indo-China, Siam,
Straits Settlements, Federated Malay States and Dutch East Indies, continued
in 1933 to aid the Bureau in this direction, and there is every reason to believe
that in 1934 this material assistance will continue.
en er al.
The work of the Bureau necessitates close co-ordination between the indivi
dual members of the staff. The fact that throughout the year there has been no
delay in circulating the information received, nor any inaccuracies due to lack
of care in preparing returns for circulation, is a tribute to the unvarying interest
and enthusiasm displayed by the staff in their daily work. Additional duties have
been thrown on the Deputy-Director during the short visits which were made to
China and Java, and these have been faithfully performed by him.
Interest will be added during the coming year by the holding of the first
international malaria course in Singapore, which will bring the Bureau into closer
contact with representatives of Eastern countries who are engaged in the campaign
against this disease. This interest will be added to by the presence of the Secre
tary of the Malaria Commission, who proposes to make the Bureau his headquarters
for a period of the year.
G L. PARK,
Singapore, 30th January, 1934.
SPREAD O F PLAGUE BY M ARITIM E TRAFFIC.
At the last meeting of the Advisory Council it was suggested that the
Bureau might make a study of the conditions under which ships became infected
with plague. The study of this question leads so naturally to that of the spread
of plague by maritime traffic that it will be considered under that heading.
A great deal of information is in our possession concerning themethod
of introduction of plague into countries and its spread subsequently.From this
we can say that the risk of plague infection being introduced into a country
will bear a relationship to:
1. The extent of the trade with plague-infected countries;
The type of merchandise imported from these countries;
The time of the year such merchandise is exported;
The sanitary condition of the ships in which merchandise is carried
as regards rodent infestation, including rat nests and their fleas;
Distance of ports of arrival from plague-infected ports of departure;
The condition of the ports of arrival as regards rodent and flea
prevalence and species;
The time at which rat-attracting cargo arrives in relation to the "plague
season” of the country of arrival;
The quarantine measures taken at the ports of arrival to prevent
importation of plague.
Consideration of the available information indicates that the present
pandemic of plague may be regarded as having invaded Canton early in 1894.
The epidemic reached its height there in May and in that month spread to
Hongkong, from which port it appears to have been conveyed to the ports of
many different countries. Gill says that the precise date of its arrival at Bombay,
and the mode of its introduction, are unknown, but in March 1896 a strange
disease preceded by rat mortality made its appearance amongst dockyard labourers
engaged in loading ships employed in the China trade.
Egypt:— Wak.il states that the present epidemic in Egypt followed a free
interval of fifty years and began in 1899. The possible direction of spread was from
Bombay to Suez and thence to Alexandria by rail. Grain sacks containing infected
rats or fleas were presumably the medium of transfer.
Plague is also said to have been introduced in 1898 into Madagascar from
Bombay, the first victims being natives employed in unloading a cargo of rice
South Africa:—Referring to plague in South Africa, towards the end of 1898,
Mitchell mentions the arrival at Lourenzo Marquez of the steamer “Gironde”
from Tamatave, Madagascar, which was reported to have cases of plague on
board. The vessel returned to Madagascar, but in November 1898 suspicious
mortality amongst rats occurred in a certain quarter of Lourenzo Marquez. In
January 1899 four cases of bubonic plague in male Indians occurred in Lourenzo
Marquez, all in one house. Another case, in an Indian who had arrived in
Lourenzo Marquez from Bombay on January 5th, but had been quarantined until
January 26th, was found on February 6th. A sixth case was found in Lourenzo
Marquez on February 7th. About the same time an outbreak occurred on the
steamship "Rajpootana” a few days out from Delagoa Bay, the first case being
a fireman who had been taken on at that port. The probabilities are, therefore,
that the infection of this port was brought from Bombay also.
In 1900 the first case occurred at Durban and it was considered probable
that the infection had been conveyed with clothing from Mauritius, which had
been infected possibly from Madagascar in 1898. The infection did not take
place until two or three weeks after the patient’s arrival, and, if the source was
as stated, the infected flea must have remained alive for about two weeks.
There is a definite history of a plague-infected vessel arriving in Table Bay
from Rosario in March 1900, and a probability that forage infected by rats or
fleas from Cape Town was responsible for a small outbreak later in the year at
Izeli. The portion of the port area of the Cape Town docks which had been in
the hands of the military authorities was infected with rodent plague in 1900,
doubtless from the importation of grain from Rosario, Buenos Aires, Rio de Janeiro
and other South American ports. This led to a severe epizootic and human
epidemic in Cape Town in 1901. Again, in 1901, plague-infected rat carcasses
were found in the harbour area of Port Elizabeth, near a large stack of imported
forage from Buenos Aires.
Cape Town is regarded as the source from which the infection spread to
Mossel Bay, the medium being rats or fleas in crated goods or other merchandise.
Another instance of the arrival of a plague-infected vessel was supplied by the
"Nevassa” which reached Cape Town in March, 1903, from Bombay. Although
the vessel reported freedom from plague, one death from that disease took place
among the crew on the third day after arrival, and four further cases among the
crew and immigrants subsequently occurred.
Plague-infected rodent carcasses
found during fumigation indicated that there had been an epizootic among the
rats on board. A vessel from South American ports carrying forage to Durban
is regarded as the probable source of introduction of the disease in 1903.
The transport of the infection by rail in grain, forage or crated goods
is regarded also as the source of infection of Johannesburg. Instances of how
this can happen are given by Mitchell, who refers to a rat dead of plague
being found in a stable at the Police Camp at Thomas River, about thirty yards
distant from a water tank on the railway line at which goods trains frequently
stopped. This rat is thought to have left the train while the engine was taking
water and made its way to the stables. On another occasion an apparently sick
rat was observed leaving a truck which had recently arrived from a plague-infected
port. This rat on examination was found to be plague-infected.
Japanese Empire:—Formosa was invaded in 1896, but it was not until 1899
that the first outbreak of plague took place in Japan proper. The disease has
also been introduced on several subsequent occasions. On the first occasion it
commenced in Kobe and spread to Osaka; the next outbreak, in 1902, commenced
in Yokohama and spread to Tokio, and the third commenced in Osaka in 1904.
In each instance the medium of introduction of the infection was considered as
being raw cotton imported from Bombay, although Chinese rice from Hongkong
may have played a part on the first occasion.
Australia:—Plague first appeared in Australia at Sydney in January, 1900,
and it was regarded as likely that the disease had been introduced from Noumea,
where there were human cases in December 1899. An extensive epizootic was de
finitely determined to have existed in Sydney in January of 1900, and the spread to
Queensland, which took place in the same year, was probably due to the transfer
of infected rats from Sydney. In the epidemic in 1921-22 the first cases were
found in Brisbane and, although the source of infection was not determined, there
seems little doubt that the subsequent transfer to Sydney (which was discovered
four weeks later) was effected by infected rats or fleas conveyed in merchandise.
Here plague-infected rats were found on wharves where vessels from Brisbane and
other Queensland ports had been berthed. The fact that the infection in Queensland
was undetected for some time after its introduction permitted unrestricted transfer
of potentially dangerous merchandise to other ports to be carried on for some weeks,
and this easily accounts for the spread to so many coastal ports.
Malaya:—Plague made its first appearance in Penang in 1899 and
could have been introduced either from Hongkong or British India, with both of
which centres there are regular trade communications. It may be significant that
36 of the 38 deaths which occurred were among Chinese, but this is the predomina
ting race. All cases were among residents, the majority of whom had lived in Penang
over a year.
It was not until 1901 that human plague was discovered in Singapore
among the indigenous population.
In 1895 one vessel from Hongkong had
been under observation suspected of plague infection, and in each subsequent
year preceding 1901 infected vessels had been arriving.
French Indochina:—In Kouang-Tcheou Wan, in 1900, plague was found
to be endemic. The disease was also discovered in Cochin-China in 1906 and is
said to have been introduced by rats conveyed in the interior of bales of goods
belonging to Chinese immigrants from Canton and Hongkong which were infected.
On opening the bales the rats escaped into the Immigration building and subse
quently infected the neighbouring houses.
Siam:—The first authentic case in Bangkok was discovered in 1904 and
is thought to have been brought by Indian traders from Bombay, because the
cases occurred in the Indian settlement on the west bank of the river.
Burma:—Plague was found in Rangoon in February, 1905, and the outbreak
first became noticeable in the Mussalman quarter where there are large grain stores.
It spread gradually, but lingered in the coolie lines of the rice mills in East and
South Rangoon. This outbreak had been preceded by the arrival in each of the
preceding four years of infected vessels from ports of British India.
China:—Plague infection among the rats in Shanghai was first noted in
1908 and persisted till 1915. Both in 1908 and again in 1920, when two plague
rats were found, the location was in the proximity of wharves where ships from
plague-infected ports are berthed.
The reappearance of plague in Manila in 1902, after an absence of six
years in human beings and five years among rats, was preceded by the arrival of
three vessels from Hongkong, each of which had a fatal case of the disease on
board. The source of infection of the port was thus regarded as being infected
rats among cargo, and it is pointed out that (1) foodstuffs, such as eggs, garlic,
onions, arrive in great quantities from Canton and Amoy, which are less than
five days’ steaming distance; (2) glass and chinaware are imported in quantities
from japan. As in South Africa, one plague case in Manila seems to have been
infected by fleas fourteen days after these were infected.
Java:—Plague appeared in Java in March 1911. It was thought by de Vogel
that rat plague was probably imported into Sourabaya with the extraordinarily large
quantity of rice arriving from plague-infected ports of British India and China
during 1910. It is supposed that through repeated transportation of plague rats
and vermin the epidemic was brought about. However, the explanation of why
the epidemic should have settled in the hinterland and not in the seaport towns
was not forthcoming.
The connection with the rice trade was shown clearly in the capital towns
Kediri and Malang, where the store houses used by the importers of rice are
situated in the middle of plague centres and where in several cases the guards
contracted plague. Also, in certain instances where the rice stores were used as
dwellings, the inmates have been infected with the disease.
From Dampit, a storehouse of British India and South China rice, the
spread of the disease could be traced southward along various routes. At Deli
(Sumatra) two cases of plague were traced to the importation of Rangoon rice
in bags. Plague rats were found among the rice bags and the people infected
were the guards of a rice storehouse where only Rangoon rice was stored.
Again in Garoet the spread of the disease has been connected with the
distribution of rice from the storehouse which apparently housed infected rodents
and fleas. The initial case in Garoet is said to have been a workman who over
hauled a motor vehicle which runs to and from Bandoeng and conveys both
passengers and merchandise.
Ceylon:— Hirst states that in January, 1914, plague was brought to Colombo
from Rangoon via Negapatam in shipments of rice. For practical plague preventive
purposes in Ceylon he says that attention should be concentrated on the grain
and cotton trades. An idea of the extent of the grain traflic is found in the
report for 1932 on port health work in Ceylon, which states that one of the
chief sources of danger to the island in respect of plague is "the grain traffic with
Rangoon and other Burmese ports—some 6,000,000 bags of rice are imported
annually, of which more than 4,500,000 come from Rangoon.”
This chronicle of events clearly indicates not only the most potentially
dangerous types of cargo, namely, rice, cotton, other grain and foodstuffs, but
also the dangerous ports, namely, Bombay, Rangoon and the grain-exporting ports
of South America. While rice is perhaps the most important grain medium in
which plague rats are conveyed, wheat, maize and other grains from South American
ports also play a part, as is seen from the number of
plague-infected vessels which
from time to time arrive in European and other ports.
The importance of raw cotton as a medium for the transport of plague
has received renewed attention as a result of the rat flea surveys of Madras
Presidency, carried out under the supervision of Colonel King, which showed that
not only the grain trade but also the cotton trade was a very important medium
for the transport of fleas.
W riting of Madras itself, King and Pandit say: "the importance of the
cotton trade in the dispersal of Cheopis was made apparent.” Cotton they
regard as a particularly suitable material for this purpose because of the shelter
from mechanical damage and from drying that it affords. Hirst says that it
would appear that, weight for weight, raw cotton is an even more dangerous
vehicle of Cheopis than grain or any other kind of merchandise.
At Kenya it was found that rat fleas were carried in hides and in bags of
cotton seed, while Thornton, discussing plague in Uganda, says that undoubtedly
the spread of plague during the last twenty-four years has been closely associated
with the ramifications of the cotton industry.
It is the importance of the rice and cotton traffic, together with the presence
of endemic plague in each, that makes ports such as Rangoon and Bombay so
dangerous. The chief rice-exporting countries are Burma, Siam and Indo-China,
and the ports, Rangoon, Bangkok and Saigon. The main importing countries
in the East, on the other hand, are Ceylon, Dutch East Indies, Straits
Settlements, Federated Malay States, China and also British India. This may be
regarded as a "local” trade between the great rice-eating countries of the East
by which any deficiency in one area is made up from the surplus of another. This
"local” trade accounts for fifty to seventy-five per cent of the exportable surplus,
the balance going to European countries, Africa and Australasia, all of which import
Raw cotton is grown in various parts of India, but mainly in the hinterland
of Bombay, and is exported in considerable quantities from the port of Bombay.
Some cotton is also exported from Karachi, but wheat is the more important
export from this port, which Hirst says has never been regarded as an exporter
Foodstuffs were incriminated as the medium of introduction of plague rats
into Manila in 1912 by Heiser who refers to the enormous quantity of food
supplies and other cargo that come directly from plague-infected centres of China.
PLA G U E SEASON.
The time of the year at which rat-attracting cargo is exported may have
a distinct bearing on the risk of plague introduction. Hirst points out that in
Rangoon plague has a spring peak in April and a summer peak in July, and it is
during the south-west monsoon, June/October, that the rat population in the
rice stores is greatest. The winter crop of rice is harvested, and for the most
part milled, in the dry weather, and may be less dangerous, although conditions in
Rangoon are at all times more or less suitable for plague.
The plague season in Bombay port is from Februaryto Mayand in the
Presidency during September and October.
King and Pandit, after pointing out that the importation of X. Cheopis
into certain places in Madras Presidency is irregular, suggest that this is due to
seasonal factors, and depends on whether the supply of cotton to a mill is from
the summer or winter cotton crop. If the latter, the infestation with X. Cheopis
is likely to be considerable.
In Bellary they found that during the hot season 27.2% of the rats trapped
were without X. Cheopis, as compared with 3.4% in the cold weather. This is
suggestive of how seasonal factors act in stopping plague.
In the plains of Punjab, and United Provinces also, during the spring season
the rat-flea index may reach 20. Here devastating epidemics may occur, but
come to an end when the flea index falls to a minimum in the hot weather.
This same factor operates also in the case of the importing country.
Infected plague rodents landed into a port during the off-season for plague
would be less dangerous than if their arrival were timed at such a season as is
most favourable for the development of X. Cheopis. This would be of more
importance where conditions are very much against the flea in the off-season.
From Brooks’ work it is seen that the combined effects of temperature and
saturation deficiency have an influence on the incidence of plague epidemics. Even
in places such as Mauritius, where the climatic conditions are at no time unfavour
able to the spread of plague, its introduction during the warm weather did not
lead to an epidemic, but with the arrival of cooler weather a rapid increase in the
number of cases took place.
The factor on which the influence of temperature and saturation deficiency
is felt is the flea, and King and Pandit found that in Madras a mean monthly
temperature above 81°F., and a mean monthly relative humidity below 76 per
cent, are the conditions which mark the long off-season for plague in the south-eastern
area. They consider that it is not so much the severity of the hot weather in
temperature or dryness that causes conditions unfavourable to Cheopis as the
much longer duration of these conditions. Such unfavourable conditions are
responsible for the failure of X. Cheopis to spread, despite much importation.
Hirst concludes that severe epidemics are not to be expected in tropical
islands, such as Ceylon or Singapore, since they are subject to an equable tempera
ture. The position of the ports of Java is interesting; these have probably been
repeatedly infected, but the disease does not tend to become endemic or epidemic,
although in the mountainous region in the hinterland this has occurred. It is
probable, however, that climatic conditions in these ports, just as in Madras, are
for a considerable duration of time unfavourable to breeding of Cheopis; accepting
Petrie’s criterion that the range of temperature most favourable to breeding of
Cheopis means the number of hours per week or per month during which the
temperature is within the limited range of 68°F. to 78°F.
There has also to be considered the effect of temperature and relative
humidity on the actual transmission of plague by infected fleas. The Indian
Plague Commission and, much more recently, Webster and Chitre, working in
Bombay, have found that experimentally B. Pestis is more readily transmitted
during the plague season than during the off-season. The favourable climatic
conditions in the plague season do not appear to affect the number of infected
fleas, but to enable a larger proportion of them to transmit the disease.
M EASURES AT PORTS.
The condition of the ports of arrival as regards rodent and flea prevalence
and species is a very important factor in determining whether plague is likely to
cause an epizootic even if introduced. It may be accepted that, by whatever means
rat fleas are transported, they will in their new surroundings select either their true
host—the rat—or the next best available animal. Plague-infected rat fleas can
thus start an epizootic if introduced among the rats of an uninfected locality.
Obviously, however, if the authorities of the uninfected locality have taken measures
to rat-proof the wharves and godowns, and to wage an incessant campaign against
rodents, the chances of such an epizootic being set up are greatly lessened. W ithout
proper harbourage rats have a Cheopis index too low for the continued transmission
of plague, hence the necessity for eliminating such harbourages is the most important
measure for preventing the spread of bubonic plague if introduced. Infected
rodents, however, may be conveyed in merchandise far outside the port area of a
city, so that measures must be widespread in the ports, and cargo, if suspected, must
be treated in some suitable way if the danger is to be obviated.
The importance of flea species, if an epizootic is to be maintained after
introduction, has been clearly shown by Hirst in Colombo. X. Cheopis has been
imported into Colombo along with other species, and the endemic plague area
corresponds almost exactly to the densely Cheopis-infested zone. When the regional
Cheopis and Astia indices were plotted against human plague mortality for a stated
period the correlation between plague incidence and Cheopis prevalence was mani
fest, but no visible correlation between Astia prevalence and plague could be seen.
Plague has since spread, but all the outbreaks appear to have originated in bazaar
areas, which suggests the probability of the transfer from the plague and Cheopisinfested area of Colombo.
Only one pure Astia region—Galle—has been infected, and this was traced
to oversea importation. The epizootic here was in a very congested and rat-ridden
commercial area and was limited in extent. King and Pandit found in Madras
that in several places where Cheopis was probably absent, and Astia or Astia and
Braziliensis abundant, plague has either not occurred at all or has caused only a
few mild epidemics, and they have not carried over from one season to another.
The evidence is definite that places where practically only Astia exists are not
likely to get severe and recurrent epidemics.
This confirms the experimental work of Webster and Chitre which led
them to believe that, where a specifically pure flea population is concerned, a
higher Astia index is required for the continuance of epizootic plague.
found that an epizootic could be re-started with an Astia flea index of 7. On
the cessation of the epizootic the index was found to be 3.2. Under the most
favourable conditions they conclude that the necessary Astia index may be between
these figures, but under natural conditions it is probable that a still higher index
would be required.
Hirst states that in Ceylon the presence of a practically pure Astia zone in
the vicinity of an outbreak in a secondary Cheopis area has doubtless served to
limit the spread of infection.
King and Pandit conclude that in South India the flea species factor is of
the first importance in the spread of plague under natural conditions and that
X . Cheopis is undoubtedly the chief vector. As regards prevalence, Hirst and
Grubbs suggest that one Cheopis is the critical flea index for the spread of plague.
King and Pandit were so struck with the far greater efficiency of Cheopis
as a vector in nature, and with the evidence that the species is of comparatively recent
introduction, that they suggest that the explanation of the recent history of plague
in India from 1896 onwards, and why this is different from previously recorded
epidemics, which rapidly died out, is that, whereas previous epidemics occurred in the
absence of Cheopis, in 1896 infection occurred when Cheopis was fairly widespread
throughout India as a whole. They suggest that the dissemination of Cheopis
occurred after the extension of human intercourse and trade (particularly the cotton
trade) with Egypt, following the opening of the Suez Canal in 1869.
CONDITIONS O N SHIPBOARD.
Not every ship offers the same attraction to rats and their fleas. Reference
has been made to the cargo that attracts them, but, after transfer to a ship among
such cargo, the conditions of life on board will play a part in the subsequent
developments. Harbourage is essential if the rats are to breed, and water, as well
as food, must be obtainable. The existence of a rat population on board will
play a part, particularly if there is a scarcity of food. An existing rat population
may, however, provide a colony of fleas to which the transfer of B. Pestis from
infected rodents can take place and, on the other hand, the carrying aboard from
an infected port of infected fleas could lead to an epizootic among an existing
rat population in the absence of the transfer of rats themselves. Buxton has
drawn attention to our lack of knowledge of the climate of the places where fleas
actually live, and this may be important in ship transfer of plague if the route
taken is unfavourable for their life and development. The rat nests may also
contain infected fleas which remain behind after unloading of cargo, even where
the rats themselves are removed, and may thus start an epizootic independently of
the introduction of fresh infection.
RAT A N D F LE A TRANSMISSION
There is also to be considered the question of the relative part played by
the rat and the flea in the transfer of plague from one port to another.
Rat fleas may be carried with merchandise or clothing and could transfer
the infection to a susceptible animal. Numerous rat fleas, for example, were
found in bran kept in a bin in a rat-infested room, while grain and cotton, as
already pointed out, form excellent media for their transfer.
Mitchell regards the case of plague at Durban in 1900 as caused by direct
infection from a flea conveyed in clothing from Mauritius, and in this case the
flea must have been infected not less than fourteen days previously.
In the absence of any host it is generally stated that adult fleas will die
in about five days, but that larvae and pupae could be carried in merchandise for
one or two months, although plague bacilli do not survive in these stages of
development. The longevity of infected fleas varies, however, with the tempera
ture, being much greater at low temperatures.
Hirst concludes from available evidence that, when an oversea source of in
fection is but a few days removed, an infected flea may be readily transferred directly
in grain from the port of origin to the port of entry. Otherwise it may be inferred
that a plague epizootic has occurred among the rats on board. But he goes on
to say: "the link between the ship epizootic and the shore rat or the rats of the
lighters into which the cargo is loaded or unloaded may be plague rats, but is
much more likely to be a plague flea.” A rat-flea survey of grain ships in Colombo
harbour in August 1928 showed that 95 per cent of the fleas caught on rats were
X. Cheopis. Similar results have been reported from New York and from ports
In Liverpool an investigation in 1929 showed that all the rats obtained from
ships were black, and that X. Cheopis occurred freely on them.
Only isolated specimens of this flea species were found on rats obtained
from the docks and city.
In 1932 not a single X. Cheopis was found on over 600 rats caught in the
Port of London.
A study of rat-fleas on Japanese ships in 1931-1932 showed that about 50
per cent of the rats were infested and that the X. Cheopis index was high, averaging
In Rangoon, X. Cheopis comprised 80 per cent of the fleas caught on
rats on ships in port, but only 12.9 per cent of the fleas on barges in the river,
5.2 per cent of the fleas on rats caught in the port and 24.7 per
cent of the fleas
on rats caught in the town area.
W e can agree with Hirst, therefore, when he says that the conditions on
shipboard along tropical and subtropical routes are specially favourable to the
preponderance of the plague flea, X. Cheopis.
Over what distance the transfer of the infection by fleas on shipboard can
take place without the intermediary of a rat epizootic does not seem quite so
clear. It has been stated that, allowing for the longest
recorded timethat an
unfed adult lives, there is no difficulty in accounting for active adult fleas being
found under favourable situations where there have been no hosts for considerable
periods—in the case of X. Cheopis, for ten months. It is quite conceivable that
favourable situations could be found on board ship, in rat nests for example, but
whether this would apply to plague fleas is another question.
Pirie, dealing with field rodent plague, concluded that if infected fleas
were left behind in a burrow when all the rodent inhabitants have been killed,
it is only necessary for the burrow to be visited by another rodent once in two
months for a small rodent plague epizootic to be started.
S U N DISIN FESTA TIO N .
It is known that fleas may be transported in bags of grain, and experiments
have been carried on by Pandit and others in regard to the value of disinfestation
as a preventive measure. It was found that when bags of grain are kept in the
shade, fleas and their larvae exhibit a tendency to remain in, or to move into,
that portion of the grain near the surface. W hen exposed to the action of the
sun, the fleas migrate into the interior of the bags. As the temperature required
to kill fleas is 49°C, maintained for forty-five minutes, and as these conditions
were reached only on the surface of the bags and just below, it was concluded
that this method is of no practical value in plague prevention in the climate of
It is suggested further that the transportation of infected fleas is unlikely
when the journey is of several days’ duration, because the life of fleas [Astia)
in the experiment (which however was carried out in the hot season) was found
to be not more than three days. (Ind. Jour. Med. Res. April, 1933).
H U M A N TRANSM ISSION.
The role of man himself in conveying plague from one country to another
hardly needs discussion. H e could only be a real danger if a carrier of infected
fleas, and this contingency is very remote. Instances have been recorded of man
being the source of infection after recovery from an attack, or in the incubation
period, but this would hardly result in transfer by maritime traffic.
Ricardo Jorge, at the October session of the Paris International Health
Office, in 1932, remarked on the important part inter-human transmission can
play in the spread of plague, and expressed the belief that in the old infections
in Europe man himself may have been the direct vector of contagion without any
intervention except that of fleas.
De Vogel, in his report on plague in Java, mentions that, according to
information supplied, the number of fleas in some of the small hotels in certain
mountainous districts of Malang was sometimes so great that people were obliged
to dress themselves standing on chairs and seats so as not to be exposed to the
attacks of the insects, which swarmed in large quantities on the floor.
Ricardo Jorge, at the October session of the Paris International Health
Office in 1932, remarked on the important part inter-human transmission can play
in the spread of plague, and expressed the belief that in the old infections in
Europe man himself may have been the direct vector of contagion without any
intervention except that of fleas.
It is well
limited in extent,
ship’s stores, who
than members of
known that human infection when it occurs on shipboard is
and often confined to the fireman or the staff dealing with the
are likely to come into closer contact with the rodent population
other departments of the crew.
The quarantine measures which can be taken to prevent the introduction
of plague have been specified in the Paris Convention. The greatest risk in
practice is the ship with an uneventful history, carrying rat-attracting cargo, e.g.
grain (particularly rice), cotton, gunny bags, hides, etc. from plague-infected
ports. Such vessels can be medically inspected to determine whether the condition
of the ship corresponds to the definition of a healthy ship, but deratised only
in exceptional cases, and after the discharge of cargo, unless the cargo is loaded in
such a way as to enable the total destruction of rats to be effected. As the operation
must not last longer than twenty-four hours, this is a practically impossible task. In
consequence, the Quarantine Commission of the Paris International Health Office,
declared that ships presenting the dangers mentioned above could at the expense of
the health authorities be fumigated before unloading, if this were considered neces
sary. The question of fumigation both before and after unloading has been further
discussed, and a proposal made that the appropriate article of the Convention
might be revised to permit dératisation being carried out before unloading where
rodent plague is present, and, in addition, a subsequent operation after unloading
if live rats are still found. The Convention, however, provides that all ships must
be periodically deratised, or be permanently kept in such a condition that the
rat pooulation is reduced to a minimum and, if the latter condition were general,
the possibilities of transfer of plague would be correspondingly reduced.
The position is definitely helped by the steps which are being taken to
ratproof vessels by removing rat harbourages. As has been pointed out by Grubbs
and Holsendorf, such harbourages may be structural, due to double walls, etc.,
incidental, due to fixtures and furniture; temporary, due to dunnage, stores, cargo,
etc. The removal of such harbourages greatly reduces the danger of propagation
and spread of plague.
Now that the rat population of a vessel can be determined with reasonable
accuracy, it is customary to examine vessels from plague-infected ports to determine
whether rats are present as a preliminary to deciding what treatment should be
followed. W hat this treatment will be depends on the views of the health
authorities as to the dangers involved and the most appropriate way to meet them,
but the application of the measures adopted constitutes another factor in determin
ing whether plague will be introduced.
Briefly it can be said, therefore, that the essential factors in the transfer
of plague by ships are:
Where there is a plague epizootic and from which there
is a transfer of rat-attracting cargo which may be infested with rodents
and/or X . Cheopis, either or both of which are infected. Rice, other
grains and foodstuffs, and raw cotton are the most important types of
Ships trading with infected ports which have:
good harbourage for rats;
(b) food and water available for rats;
possibly a rat population already.
A suitable duration of voyage:
if less than five days, transfer could take place by infected fleas
if longer, transfer would probably depend on an epizootic on
board which was still active on arrival or at least had left behind
conditions of temperature suitable for flea life and development.
Ports of Arrival:
Unloading of merchandise containing infected rats and/or fleas,
and suitable conditions ashore:—
for rats to live and breed;
X. Cheopis to breed;
for rats and fleas to transfer to the shore and join the local
of climate at the time the infectionarrives;
Where quarantine measures prove ineffectual.
A N N E X II.
SPREAD OF CHOLERA BY M ARITIM E TRAFFIC.
A t the last meeting of the Advisory Council it was pointed out by the
delegate from Australia, during a discussion on the spread of cholera, that,
although there had been close communication between infected Asiatic ports and
Australia over the past eighty years, in one case only had a ship arrived with
an outbreak of cholera on board. In this instance there was no case among the shore
population. It was suggested that the conditions under which cholera is spread
by maritime traffic might be studied.
The conditions under which such a spread might take place presuppose
a combination of conditions which include:
Cholera-infected ports ;
Cargo contaminated by choleravibrios
e.g. fruit, fresh vegetables, oysters;
Infected water being taken on board;
from such ports during either
of incubation of thedisease,
being taken on board,
(d) Infected clothing being taken on board.
A possible spread of infection on board which leads to:
(a) Persons incubating the disease;
Becoming ill on board, or
(c) Reaching the convalescent stage without definitely recognised
(a) Persons landing at a subsequent port in any of the conditions
2 (a) i, ii, iii;
(b) Consumption of infected food or water from an infected port;
(c) Indirect infection from clothing;
Conditions in the port of arrival of hygiene and climate suitable for
development of the disease;
Breakdown of measures imposed at ports of arrival to prevent infection.
INFECTED COU NTR IES.
Man himself being the agent of spread of cholera, the importance of a
port as a focus for transferring the disease will depend not only on the prevalence
of the disease in it, but also on the extent of its passenger traffic, particularly of
immigrant or pilgrim type. The main endemic centres of cholera are British
India and China, and from several of the ports of both countries there is a
regular immigrant traffic. Although the extent of this traffic has been much
reduced owing to the economic depression, there were in 1932 more than 17,000
immigrants into Malaya alone from Southern India (cf. 93,500 arrivals from
Southern India in 1927). This traffic is a regular one from month to month.
These immigrants come from the ports of Madras and Negapatam, in
both of which cholera occurs, though with much greater severity in some years
than others. There is also a large immigrant traffic between Southern India and
Ceylon and between Northern India and Burma. In 1932, for example, more
than 250,000 passengers and 80,000 crew were inspected at Rangoon on vessels
arriving from Indian ports.
In addition to the very large passenger traffic between Calcutta and Rangoon
there is a smaller but still considerable passenger traffic between Calcutta and
Malayan ports. Calcutta is the main endemic cholera focus among the ports of
British India and is never free from the disease. There is, however, a definite
increase in incidence during the first half of the year, which makes this period
the more dangerous from the point of view of transfer.
From certain ports in China, particularly Amoy and Swatow, there is also
a very large regular immigrant traffic to Philippine Islands, Dutch East Indies
and Malaya. Cholera occurs from time to time in both of these ports in epidemic
form, but is probably not endemic in the ports themselves. From Shanghai, Canton,
and other Chinese ports which are visited by cholera in epidemic form, there is
also an enormous passenger traffic, and, owing to the commercial importance of
the former, ship infection is not infrequent.
O f other ports, Bombay and Rangoon have recorded a cholera situation
more favourable since 1931 than in some previous years, and since 1930 the
position has improved a great deal in Bangkok, and also in Saigon and Pnom-penh.
The risk of transfer from these ports is also lessened by the absence of the large
scale immigration that is a feature of the other ports of British India and China
that were previously referred to.
SHIPBOARD IN F E C T IO N .
That the occurrence of cholera on board ship is relatively frequent is shown
by the records of ports, such as Rangoon and Penang, which are constantly
receiving large numbers of passengers from Calcutta and Southern Indian ports.
In the five-yeav period 1928-1932, thirty-one cholera-infected vessels arrived
at Rangoon from Calcutta, while in the twenty years 1912-1931 there arrived at
Penang from British Indian ports seventy-six cholera-infected vessels. Similarly
in 1932, during the epidemic of cholera in Shanghai, fourteen vessels were infected.
In all of these instances the original infection can be presumed to have been
contracted ashore. The infected vessels arriving at Rangoon were at sea on the
average above forty-eight hours, and during this period there was no extension
of the disease on board.
Very different, however, is the case where the distance is a little longer,
e.g. to Penang—a steaming distance of 3 /6 days. Here the records show multiple
instances of cases subsequently developing among the contacts while under obser
From 1905 to 1924 more than 1,000 cases of cholera were treated at the
Penang Quarantine Station alone. In the year 1924 itself forty-six cases of
cholera had been admitted to the station from ships and 105 cases developed
among contacts while under observation. From one vessel, which arrived infected
from Madras and Negapatam, seventeen cases developed among the immigrants
landed at the Quarantine Station. Another vessel from the same port arrived
less than a month later with a history of thirty-one cases during the voyage.
Among the contacts quarantined from this vessel 179 cases occurred.
Again in 1926 a vessel from these ports arrived at Penang with a history
of twenty-three cases of cholera on board, and later sixty more cases developed
among the quarantined contacts.
The history of a small outbreak limited to one section of the crew of a
vessel may be noted, as it was over before the cause was definitely ascertained.
This vessel left Singapore on the 17th October 1927, where she had been since
the 14th, with a crew of 142 people and 35 passengers, none of whom were
in the deck class. Cholera was not known to be present in Singapore, but
actually existed. On the evening of the 17th the bar steward (Chinese) became
ill, and after arrival at Batavia on the 19th was taken ashore, where he died. A
post-mortem diagnosis of cholera was subsequently made, but the information
was not available on the steamer till the evening of October 25th.
On the 18th:
Two other Chinese became ill with gastro-enteritis; they
remained on board and recovered.
Vessel left Batavia and three more of the Chinese crew
were taken ill.
» 22nd: Vessel spent three hours at Samarang.
Vessel spent seven hours at Sourabaia.
Chinese baker died.
Vessel spent four hours at Macassar; the three patients
were disembarked, one of whom recovered.
The other two patients died.
Another passenger suffers from gastro-enteritis but after
The number of cases was thus eight, but one, at least, according to the
report, was not considered cholera. All occurred amongst the Chinese crew and
the probabilities are that there were two series of cases, one infected at Singapore
and the other on board. After the vessel left Macassar steps were taken to
disinfect the quarters, bedding and linen. No further cases occurred, and on
examination at Sydney, where the vessel arrived on November 5th, all were well
and no persons carrying vibrios in their stools were discovered among the native
In another instance a vessel carrying a large number of immigrants was
infected at a port of call where the passengers had gone ashore. In this instance
the infection was not manifest until seven days after arrival at the infected port,
during which period the vessel had proceeded on her journey and spent 1/2
days at a subsequent port of call. As soon as the disease was recognised the vessel
returned to port, but cases continued to occur for fourteen days among the contacts
in quarantine. Altogether, fifty-four cases with seventeen deaths occurred.
Another interesting shipboard infection may be recalled, namely, that of
the S.S. "Cathay” which arrived in Kobe on the 22nd August, 1931, with a case
of cholera on board four days after leaving Shanghai. In this instance the crew
had not been allowed ashore, but food had been transferred to the vessel
from local craft while in port, and doubtless accounts for the infection.
It would seem clear from these examples that cholera infection on board
ship produces clinical evidence of its presence at an early date, which is only
what is to be expected owing to the short incubation period and the nature of
L A T E N T IN C U B A T IO N PERIOD.
Although the incubation period is generally accepted as being one to five
days, there have been suggestions that the disease has a latent period.
Munson referred to this question and its influence on quarantine practice
during the 1914 epidemic in Manila, where some carriers were found to develop
symptoms within the incubation period, but others only after longer periods up
to 16/18 days.
Doorenbos draws a distinction between an epidemic type of vibrio and an
endemic type, and between epidemic and sporadic cholera. He says that epidemic
cholera has a very short incubation period, but that this period may be very long
in the sporadic type. The endemic type of vibrio, however, has been acted upon
by bacteriophage and would not regenerate except under specially suitable conditions.
SPREAD BY M A N .
Man can only spread the disease during the times at which he is excreting
cholera vibrios, i.e. during the stages of incubation, symptoms and convalescence.
The incubation stage may be the most dangerous because, during the time it lasts
—a few hours up to five days—an individual could travel from one place to
another and become a source of infection in the new locality.
The method of transmission is by the introduction into the stomach of
material contaminated with cholera vibrios. The commonest medium is probably food,
certain articles of which, such as raw vegetables and fruit, are liable to infection
by being handled with infected fingers, and are subsequently consumed without
treatment. Fish is regarded in Japan as a most important article of food in the
spread of cholera. Takano found that in October cholera vibrios smeared on
fish-meat survived from three to four days, and in the ice chest ten to twelve
days. Fish may be contaminated by seawater, the pollution of which is of frequent
occurrence. Oysters and other shell-fish may also be polluted by seawater, and
no suitable method exists of disinfecting fish and shellfish except boiling. Drinking
water also forms a suitable medium for spreading the infection, and that infections
of public water supplies have produced explosive outbreaks has long been recognised.
Direct contact may also be an important factor in transmitting the infection where
the sick are tended by their friends and relatives. These people get their hands
soiled and convey the disease to themselves and to others.
The history of an epidemic in Assam, described by Colonel Morison,
illustrates the possibilities of spread. This epidemic was traced to a single case
infected 200 miles from the scene of the epidemic, to which he was travelling by
train. H e took ill on the train and died a few days later. Four cases occurred
subsequently in the family of a man who visited the house of the first case. This
family lived on the banks of a river and cholera broke out in twenty-six villages
lower down, resulting in 699 cases. The cases due to river infection numbered
about thirty-two, the remaining cases were due to contact, and many were "clearly
due to ceremonial feasts held to cure the sick.”
DURATION O F INFECTIVITY.
D ’Hérelle considers that patients who recover are only infective up to the
time when symptoms definitely abate. Khan says the majority of cholera cases
get free of V. Cholerae within a few days and abate. Couvy quotes Acton as
stating that non-agglutinable vibrios make their appearance in convalescent cases
towards the fifth day and are no longer met with after the fourteenth day, and
there is more or less general agreement that cholera cases are free from vibrios
in 7/14 days after convalescence. It is unlikely, therefore, that the "healthy1’
ship is any real danger if arriving after a journey of more than five days from
a cholera-infected port.
For practical quarantine purposes we can omit the person infected by what
Doorenbos calls the endemic type of vibrio, in which category also we can place
the so-called "carrier” who develops the disease after a latent period. Considéra-
tion, however, must be given to the question of the "carrier” as defined by
d’Hérelle. This is an "individual in a normal state of health whose excreta contains
vibrios, whether these vibrios have persisted in the intestine after convalescence
from an attack of the disease or whether their presence is the result of contamination
not followed by the disease.” This is an important question from the point of
view of transfer of the disease by maritime traffic, for had we to admit that there
was a "carrier” problem in cholera it would be difficult to understand why the
disease did not continue in endemic form after its introduction into a district,
and more difficult to understand why it did not carry long distances. Fortunately
this question has recently been exhaustively studied by Couvy, who speaks of
"healthy carriers” on whom it has never been possible to blame positively a single
case of infection. If we are prepared to accept d’Hérelle’s view, there is nothing
unexpected about this conclusion, because these carriers excrete vibrios which are
REGENERATION O F
Pdsricha and others have shown that in regions like Calcutta, where cholera
is endemic, certain strains of non-agglutinating vibrios can be regenerated probably
by the actions of vibriophages and become agglutinable with cholera specific serum.
Non-agglutinable vibrios may be carried longer than the agglutinable, but, according
to Khan, probably die out in the course of 3/4 months. It is necessary, therefore,
to know whether the regenerated vibrios can produce the disease. Doorenbos
considers that the regeneration will only take place under the favourable conditions
met with in endemic cholera areas, and, above all, during certain months of the
SEASONAL IN F L U E N C E .
It is well known that there is a seasonable incidence of cholera and the
absence of suitable climatic conditions may be an important element in determining
whether the introduction of cholera vibrios, agglutinable or non-agglutinable, will
lead to the development of the disease.
The recent investigations in China suggest that epidemic cholera need not
be expected there (as in British India) unless the absolute humidity is over .4
inch. It is important to note, also, that the existing foci of endemic cholera are
situated in the Northern Hemisphere, and consequently the season of greatest
prevalence in these areas corresponds with a different set of meteorological con
ditions from those found in the Southern Hemisphere at the same time of the
year. For instance, in Shanghai, July, when the peak of the cholera season is
reached, is mid-summer, but in Sydney, for example, it is midwinter. Records
show that the vessels which were known to be infected in Shanghai in 1932 left
that port in the four months June, July, August and September.
ponding tendency is seen in the case of infected vessels from Calcutta, where
the seasonal prevalence is in March, April and May. O f the thirty-one infected
vessels which arrived at Rangoon between 1928 and 1932, twenty-five, or 80 per
cent, arrived from March to June inclusive. It is probable that cholera vibrios
would not cause an epidemic if introduced into ports in the Southern Hemisphere
at this time of the year.
E FF E C T O F IN O C U L A TIO N .
The risk of transfer of cholera infection by maritime traffic is also minimised
to a large extent by the general belief in Eastern countries in the nature of
inoculation and by its application to passengers leaving infected ports. Deck
passengers leaving infected ports in China during the epidemic in 1932 were
inoculated before departure. The quarantine authorities in the Phillipine Islands
required that this should be done before departure for ports in that country.
Passengers and crew of vessels from cholera-infected ports for the Dutch East
Indies were also required to be inoculated before arrival, and, if this had not been
carried out, were submitted to the procedure before being allowed to land. The
same procedure is followed in regard to arrivals at Saigon from infected ports.
All pilgrims also, leaving ports of the Dutch East Indies, Straits Settle
ments and British India for Mecca, are inoculated against cholera before departure.
Although some doubts have been expressed as to the theoretical value of this
measure, and particularly of a single inoculation, it is being used, and does seem
to be of real practical value. This opinion has the support of the Permanent
Committee of the Paris International Health Office, which recently (October 1933)
expressed the view that travellers coming from a cholera-infected region should, on
entry into other countries, be accorded the facilities granted to inoculated persons
even though they have only had a single injection, so long as it is the practice
of the country whence they have come to give only one injection.
It would seem to be only a matter of time until agreement is reached as
to the conditions governing inoculation of persons leaving cholera-infected ports
for other countries which should ensure facilities being granted to them on arrival.
Once this practice under proper conditions becomes general—and it is even now
largely adopted—we may expect the transfer of cholera by maritime traffic to
become an increasingly rare occurrence. 7 here may still be some risk of transfer
at short range by contaminated foodstuffs, by mild unrecognised cases and by
persons in the incubation stage, although inoculation of the two last types may
have a beneficial effect.
PROPHYLACTIC U SE O F BACTERIOPHAGE.
The suggestion made by Colonel Morison that treatment by a mixed antidysenteric and anti-cholera phage should be carried out on all pilgrim ships leaving
infected cholera ports might well prove to be of great value, in which case its
general application in the case of crew and passengers of all vessels leaving cholerainfected ports should follow.
Larkum (American Journal of Public Health, November, 1933) says of
bacteriophage "it has been apparent that the clinical use of this principle has
suggested the role as a producer of antitoxins.” Bacteriophage, he considers, can
be used prophylactically to produce immunisation, as well as therapeutically.
In addition to inoculation of passengers embarking, mass inoculation, which
is practised—e.g. Shanghai—may have some indirect prophylactic value for
uninfected countries by limiting the extent of epidemic prevalence.
Vessels leaving infected cholera ports may inoculate passengers, and this
will be of particular value where the latter are in large numbers, and serve
indirectly to protect the ports of arrival.
The risk of introduction of cholera into uninfected countries will be
diminished by other measures which may be taken before departure from the
infected country, such as the detention and stool examination carried out in the
Philippine Islands of emigrants for overseas who have come from a known cholerainfected district.
MEASURES O N ARRIVAL.
Countries of arrival may require (as in Straits Settlements) deck passengers
from cholera-infected ports to remain under observation until the quarantine period
of the disease has expired, or may under certain conditions conduct examination
of stools to detect the presence of vibrios, as is done in Japan and Philippine
Finally, the sanitary condition of ports of arrival will have a definite
influence on what happens. The countries in which cholera is prevalent have not
yet reached the standard of public health which demands either good conservancy
or public water supplies which are above the possibility of contamination from
human sources. A t the same time, the habits of the people in those countries
conduce to close contact and provide abundant facilities for transfer of infection
from food and water.
The annual report of the Public Health Commissioner with the Government
of India for 1931 quotes the following remarks of the Director of Public Health,
Bombay, on the cholera epidemic which began in August 1930:
"From June onwards water supply is the main source of spreading
infection. This is accentuated in cases of villages situated on the banks
of a river which form the main place for washing of the clothes. The
villagers are generally careless and wash the infected clothes in the river
without taking precautions, and the villages downstream are infected.”
The points which are in favour of uninfected countries remaining free
from infection would appear to be:
1. Good hygienic conditions, both general and personal;
2. Location at a distance from infected ports which takes longer to traverse
than the incubation period of the disease;
3. Absence of immigration from infected ports;
4. Quarantine measures which enable the history of arriving ships to be
ascertained, and appropriate measures taken to meet any suspicious
5. Location where the climatic conditions do not correspond with those
of centres of endemic and epidemic cholera.
PROPOSED ESTIM A TES FOR T H E YEAR 1934.
AS APPROVED BY T H E F O U R T E E N T H ASSEMBLY.
I. Staff Salaries
II. Travelling Expenses of Staff, (Including Expenses in Connec
tion with Liaison with VariousGovernments
Co-ordination of Research)
Cables & Postage.
IV. Printing, Stationery & Equipment.
Printing SC Binding
Books of Reference
Rent, Electricity & Telephone.
Electricity & W ater
Travelling Expenses of Members of the Advisory Council
League’s Contribution Towards the Pensions Fund
Medical Attendance to Staff
PROPOSED ESTIM ATES FOR T H E YEAR 1935.
Travelling Expenses of Staff (Including Expenses in Connec
tion with Liaison with various Governments for the
Co-ordination of Research)
Cables & Postage.
Travelling Expenses of Members of the Advisory Council . .
League’s Contribution Towards the Pensions Fund
IV. Printing, Stationery & Equipment.
Printing & Binding
Books of Reference
Rent, Electricity & Telephone.
Electricity & W ater
League of Nations’ Health Organisation—Eastern Bureau.
Receipts and Paym ents Account for the Year ended 31st Decem ber, 1933.
E stim ate o f
fo r year.
Balance at 1st January, 1933
By Staff Salaries
Travelling Expenses of Staff
Cables and Postage
Printing and Stationery
Books of Reference
Rent, Electricity and Telephone
Travelling Expenses of Advisory Council Members
Contribution to Pensions Fund
A udit Fee
Advances made on a/c League of Nations, Geneva—
D t. P. J. Vidhivejj— a/c Study Tour
D r. J. A . Anklesaria— a/c Study Tour
A ir passage for D r, Rajchman, Singapore to
Cables despatched by D r. Rajchman
N a tio n s—
League Vote— Sw. Fes. 33,528.65
Rockefeller Vote— Sw. Fes. 88,526.88
League of Nations, Geneva— Refund of advances made
Sundry Creditors of 1932
Balance at 31st December, 1933—
A t Mercantile Bank of India, Ltd.
Eastern Extension A . & C. Teleg. Co., Ltd., Deposit
Municipality of Singapore Deposit
The following transfers in the Estimates for 1933 were found necessary and were made during the year:—
From Contribution to Pensions Fund
To Office Equipment
Electricity and water
C o n t r ib u t io n s —
Federated Malay States
Netherlands East Indies
E XPEN DITUR E.
T o Staff Salaries
I n c o m e a n d E x p e n d i t u r e A c c o u n t fo r t h e y e a r e n d e d 3 1 s t D e c e m b e r , 1 9 3 3 .
Travelling Expenses of Staff
Cables and Postage
Printing and Stationery . .
Rent, Electricity and Telephone
Travelling Expenses of Advisory Council Members . .
Contribution to Pensions Fund
A udit Fee
Balance being excess of Income over Expenditure
transferred to Capital Account
INCO M E.
C o n trib u tio n s —
Federated Malay States
Netherlands East Indies
League of Nations (League Vote)
League of Nations (Rockefeller Vote)
Balance Sheet as at 31st December, 1933.
L IA B IL IT IE S .
C apital A c c o u n t :—
A s per Balance Sheet 31st December 1932
A d d — Excess of Income over Expenditure
C ash and D eposits :—
A t Mercantile Bank of India Limited, Singapore
O n hand
League of N ations, Geneva.
Less— Amount transferred to Working Capital Fund
C a p ita l
Account year 1933
R e f e r e n c e :—
F u n d :—
As per Balance Sheet 31st December 1932
Sw. Fes. 471.35
As per Balance Sheet 31st December, 1932
O ffice F urnitu r e and F ittings :—
A s per Balance Sheet 31st December, 1932
A dditions since
We have examined the above Balance Sheet with the books and vouchers of the Eastern Bureau in Singapore and with the returns from Geneva
and hereby certify that it is correctly drawn up in accordance therewith.
G ATTEY & BATEM AN,
Singapore, 7th February, 1934.
Incorporated A ccountants, Auditors.
C. L. PARK,
C O M PIL A TIO N OF W EEKLY W IRELESS BU LLETIN .
Singapore, 9th June, 1933.
In view of the possibility of errors occurring in the transmission of the
Weekly Wireless Bulletin emanating from the Bureau it seems desirable to refer
to the system underlying the compilation of these bulletins.
A reference to cover page II of the Weekly Fasciculus will show that the
list of ports in communication with the Bureau is classified under the headings
of the country in which the port is situated. Countries have been geographically
arranged in this list, commencing from the Union of South Africa and ending
with the Panama Canal Zone, whereas the ports have been alphabetically arranged
under each country. The order in which ports appear in this list is strictly
adhered to in preparing the weekly wireless bulletin. The first reference to disease
in ports in any weekly wireless bulletin would thus be to the ports of South
Africa, and following these ports, to the ports of Portuguese East Africa, and so
on. A reference to any of the African ports in the list would therefore always
appear before any reference to disease in any of the ports of Asia. And, similarly,
the Eastern ports, such as, Bangkok, Hongkong, Canton, Shanghai and Kobe,
would always be referred to after the ports of British India and the Dutch
East Indies. If therefore any bulletin received is not so arranged a mutilation
has occurred, the nature of which might be inferred after reference to the bulletin
for the previous week.
Should two or three of the following diseases be present in any one port,
they are mentioned in the following order:—Plague, Cholera, Smallpox.
A bulletin in code and in clear is attached to illustrate the method of
C. L. PARK,
LEAGUE OF N A T IO N S EA STERN BU R EA U SINGAPORE.
W EEKLY W IRELESS B U L L E T IN IN AA CODE.
IK ZU F
YK ZU C
ZU FD V
DV K SU
U H E FK
KZU M J
ZU G G G
K ZU D G
E D JD J
Z IJW E H
N IN K Z
V H JH J
B U LLET IN
Week ended 13th January.
Cape Town—smallpox cases 4.
D U K ZUD
Beira—smallpox cases 2.
Tamatave—plague cases 2.
GY GY K ZU C
Mombasa—smallpox case I.
Massaua—smallpox cases 3.
D J K SU D KZUF
Alexandria—plague cases 2; smallpox cases 4.
D V DV KSUC
Beirut—plague case 1.
DGDG K E U D
Aden—cholera cases 2.
Basrah—cholera cases 4.
Bushire—cholera cases 5.
DZ K S U H
Bombay—plague cases 6.
Calcutta—cholera cases 29.
Karachi—smallpox cases 11.
JRJR K Z U T
Vizagapatam—smallpox cases 18.
H X K ZU D
Pondicherry—smallpox cases 2.
E U K SU C M D M D U F Colombo—plague case 1; infected rats (urban districts) 4.
Singapore—plague case 1.
D T KSUD
Batavia—plague cases 2.
G N K ZUG
Macassar—smallpox cases 5.
GG K ZU D
Kuching—smallpox cases 2.
GS K E U D
Manila—cholera cases 2.
Bangkok—plague cases 5.
Saigon—plague cases 2.
GM GM KEUK
Macao—cholera cases 9.
Hongkong—plague cases 3.
D JD J K EU G K Z U W Amoy—cholera cases 5; smallpox cases 21.
Canton—cholera cases 12.
Shanghai—smallpox cases 31.
J H J H K ZUZ
Tientsin—smallpox cases 24.
JS K EU C
Vladivostok—cholera case 1.
GD K EUG KZUE
Kobe—cholera cases 5; smallpox cases 3.
Sydney—smallpox case 1.
H N KSUC
Noumea—plague case 1.
Week ended 6th January.
Cairo—smallpox cases 17.
JK K Z U X
Tourane—smallpox cases 22.
Director of Eastern Bureau.
Quarantine Notifications issued by Eastern Health Administrations during 1933.
O N A C C O U N T OF PLAGUE.
Date imposed. Date cancelled.
D. E. I.
O N A C C O U N T OF CHOLERA.
F. M. S.
D. E. I.
O N A C C O U N T OF SMALLPOX.
F. M. S.
25. 1.33 &
28. 4.33 &
6. 1.33 &
No. o f
Date imposed. Date cancelled.
Chefoo (China) Hongkong
O N A C C O U N T OF T Y PH U S.
SH O R T SU M M A RY
PROCEEDINGS OF THE EIGHTH SESSION
ADVISORY COUNCIL OF THE EASTERN BUREAU
SIN G A PO R E
H eld on th e 8 th and 9 th F eb ru ary, 1 9 3 4 .
The following were present:—
- Dr. R. D . Fitzgerald,
Acting Director, Medical and Health
Services, Straits Settlements.
C h i n a ........................................................... Dr. W u Lien-teh,
Director of the National Quarantine
Service of China (Vice-Chairman).
F r e n c h In d o -C h in a
. . .
- Dr. P. Hermant,
Inspector-General of Medical and Sani
tary Services, French Indo-China.
J a p a n .................................................... Dr.
MedicalOfficer, Central Sanitary
E a s t e r n B u r e a u ................................. Dr.
C. L. Park, Director.
Dr. T . Ouchi, Deputy Director.
B r itis h C o lo n ie s a n d D e p e n d e n c ie s
The meeting was honoured by the presence of the Governor, Sir Cedi
Clementi, g .c .m .g ., who welcomed the delegates and was subsequently accompanied
by them on a tour of inspection of the Bureau.
The Chairman, Dr. Hermant, in expressing his pleasure at the presence
of thedelegates, referred to the factthat all of
them had attended one or
other of thepreviousmeetings
of the Council.
He expressed regret that
Major-General Graham would not be attending this or subsequent meetings
owing to his resignation of the post of Commissioner for Public Health
with the GovernmentofIndia.
H e eulogised the splendid work whichGeneral
Graham had performed in theinterests of the Council and desired that a record
of his service should be made in the proceedings of the meeting.
The opinion expressed by the countries represented on the Council who
had not sent delegates, that it was not desirable to convene a full meeting for
1934, but that a small meeting should be held, was conveyed to the Members
a s s o c ia t io n
t r o p ic a l
m e d ic in e .
Dr. W u Lien-teh stated that arrangements were in progress for the holding
of this Congress at Nanking in 1934, and expressed the hope that Members of
the Council would attend.
The Chairman asked that Dr. W u Lien-teh should advise the Bureau after
his return regarding the details of the meeting.
e p id e m io l o g ic a l
in t e l l ig e n c e .
Satisfaction was expressed that the arrangements made for transmitting
the wireless bulletins from Saigon on a short wavelength had not led to any
difficulties of reception. The arrangements by which the Local Director of Health,
Saigon, decoded the Bureau’s message and forwarded it to the Saigon Station
ensured that the message in clear was an accurate transcription of the code
W EEKLY FASCICULUS.
Approval was expressed of the inclusion in the Weekly Fasciculus of parti
culars of the situation in regard to minor infectious diseases. It was suggested
also that the Fasciculus might contain a monthly review of the epidemiological
situation in various countries.
A discussion ensued on the arrangements made for the first malaria course
at Singapore during which it was agreed that it might not be possible to provide
the same facilities for this course as for subsequent ones. For example, it seemed
possible that field courses might have to be confined to two countries instead of
three. The Council Members felt that it was desirable to make the arrangements
conform to the conditions which pertain instead of aiming at ideal arrangements.
RURAL H Y G IEN E .
Information was given to the effect that a satisfactory response had been
made to the request for information from various countries. It was suggested
that this information should be summarized in such a way as to render possible
a preliminary discussion at an informal meeting of the Council, to be held during
the Congress of the Far Eastern Association of Tropical Medicine after which
arrangements could be made for a final discussion, preferably during the meeting
of the Advisory Council in 1935. Delegates present gave additional information
regarding the practice in their countries, and agreed with the proposal made for
consideration of the available information.
F IN A N CIA L
The statement of accounts for 1933 and the budget for 1935 as submitted
were approved, and the views of delegates sought regarding the amounts of
contributions likely to be available in 1934. It appears likely that the Bureau
can expect approximately the same amount in contributions from those countries
which provided this material help towards
the maintenance ofthe Bureau in
A general discussion followed on the methods applied by various countries
to control the spread of quarantinable diseases, during which particulars were
given of the exact methods followed in each country, more particularly those
taken against plague and cholera. From the discussion on the value of inoculation
against cholera it was seen that there was a difference in the dosage of vaccine
used. The results obtained by the use of bacteriophage in controlling cholera
outbreaks in Assam were received with much interest, and the Bureau was asked
to keep closely in touch with the work on this subject so that countries might
be kept advised of the results from time to time.
An exchange of views took place in regard to what should be called
cholera, during which the Chairman gave an account of the difficulties in outlying
districts in his country in getting specimens sent to the laboratory early enough
for examination to be effective. H e mentioned that in some cases which had
been diagnosed as cholera clinically no vibrios at all were found.
Dr. W u Lien-teh said that the authorities in Shanghai had come to an
understanding as to what should be called cholera, and he suggested that the
Bureau might collect information which would enable the Council to come to
an agreement regarding what should be notified as a definite case of cholera.
The Chairman brought up the question of the control of tuberculosis and
venereal disease, and made the suggestion that the activities of the Bureau might
be extended in the direction of an enquiry as to what steps were being taken in
Eastern countries in regard to these diseases.
The Council approved the following resolutions:—
1. The AD VISORY C O U N C IL approves the report of the Director
of the Eastern Bureau for 1933 and records its appreciation of the work
done by the Bureau during the year and of the form in which the
report has been presented.
The ADVISORY C O U N C IL passes the accounts for the year 1933
which have been duly certified by the Auditors of the Bureau.
The ADVISORY C O U N C IL having considered the proposed Esti
mates for the year 1935, amounting to $93,406, approves this estimate
The ADVISORY C O U N C IL expresses its profound regret that
owing to his retirement from the office of Public Health Commissioner
with the Government of India it will not have the benefit of MajorGeneral Graham’s assistance at future meetings. It wishes to place
on record its high appreciation of the valuable services which MajorGeneral Graham has rendered to the Council, of which he was the
first Chairman, and over whose meetings he presided so ably during
the first four years of its existence.
The ADVISORY C O U N C IL having noted with satisfaction that the
Government of the Straits Settlements is collaborating fully in the
arrangements for the first international malaria course at Singapore,
expresses its appreciation of the efforts made by the Principal of the
Medical College in arranging the theoretical and laboratory courses of
study, and wishes to thank the Director of Public Health Services,
Dutch East Indies, the Director of Medical and Health Services, Straits
Settlements and the Inspector-General of Medical and Health Services,
French Indo-China, for providing facilities for the holding of field
courses in their respective countries.
The ADVISORY CO U N CIL, having noted that information has been
received from many countries regarding the existing arrangements for
protecting the health of the inhabitants of rural areas, considers:
that preliminary informal discussions on this subject should take place
during the meeting of the Far Eastern Association of Tropical Medicine
at Nanking, in October, 1934;
(b) that the year 1935 would be an appropriate one to arrange for a
larger meeting of the Advisory Council, as envisaged by the resolution
of the Health Committee in February 1927, and recommends that
Rural Hygiene in the Far East should be one of the main subjects
for discussion at this meeting.
The ADVISORY C O U N C IL recommends that the Eastern Bureau
should undertake a study of the methods which are being applied in
various countries of the Far East against social diseases, including in
that term tuberculosis and venereal diseases.
The AD VISORY CO U N CIL, having noted the relationship that exists
between climatic conditions and the incidence of certain diseases,
recommends the Bureau, when preparing charts showing the course of
epidemics, to include all available meteorological information.
9. The ADVISORY CO UN CIL, having noted the valuable information
and experience acquired by medical officers of Eastern countries who
have carried out individual study tours, recommends that this system
should be extended as far as financial considerations permit.
10. The ADVISORY CO UN CIL, being informed that the regulations of
certain countries prescribe that all passengers travelling by air must be
vaccinated against smallpox,
inoculated twice against cholera,
inoculated against plague,
—even if coming from countries where these diseases do not exist—
suggests that this question should receive consideration by the appropriate
authority with a view to uniformity of practice being obtained.